I 


n 


SPINE  AND  OF  CHE  NERYES, 


BY 

CHAELES  BLAND  EADCLIFFE,  M.D., 'F.E.C.P.  LOND., 

Physician  to  the  Westminster  Hospital,  and  to  the  National  Hospital  for  the  Paralyzed  and  Epileptic. 

JOHN  NETTEN  EADCLIFFE, 

Medical  Superintendent  of  the  National  Hospital  for  the  Paralyzed  and  Epileptic. 

J.  WAEBUETON  BEGBIE,  M.D.,  F.E.C.P.  EDIN., 

Physician  to  the  Hoyal  Infirmary  of  Edinburgh. 

FRANCIS  EDMUND  AINSTIE,  M.D.,  F.E.C.R, 

Senior  Assistant  Physician  to  Westminster  Hospital ;  Lecturer  on  Materia  Medica  in  Westminster 

Hospital  School. 


JOHN  EUSSELL  EEYNOLDS,  M.D.,  F.E.S.,  F.E.C.P.  LOND., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  University  College  ;  Physician  to  University 
College  Hospital,  and  to  the  National  Hospital  for  the  Paralyzed  and  Epileptic. 


: 


PHILADELPHIA: 

HEKEY     O.     LEA. 
1871. 


0,58 


PHILADKLPHIA: 
COLLINS,  PRINTER. 


PUBLISHER'S   NOTE. 


THIS  volume  comprises  a  series  of  essays,  extracted  from 
the  "  System  of  Medicine,"  edited  by  J.  Russell  Reynolds, 
M.  D.,  on  a  group  of  diseases  of  great  interest,  and  many  of 
them  of  frequent  occurrence.  These  essays  are  from  the 
pens  of  gentlemen  of  acknowledged  ability  and  experience, 
who  have  paid  particular  attention  to  the  several  diseases  on 
which  they  have  written.  The  volume  will  be  found  to 
present  the  latest  advances  in  the  knowledge  of  the  several 
subjects  therein  discussed. 

PHILADELPHIA,  November,  1870. 


CONTENTS. 


DISEASES  OP  THE  SPINAL  CORD  . 
Preliminary  remarks 

MENINGITIS       .... 
Symptoms      .... 
Post-mortem  appearances 
Causes,  diagnosis  . 
Prognosis,  treatment 

MYELITIS 

Symptoms      .... 
Post-mortem  appearances 
Causes,  diagnosis  . 
Prognosis,  treatment 

SPINAL  CONGESTION   . 

Symptoms      .... 
Post-mortem  appearances 
Causes,  diagnosis  . 
Prognosis,  treatment 

TETANUS   

Symptoms     .... 
Post-mortem  appearances 

Causes 

Diagnosis       .... 
Prognosis,  treatment 

SPINAL  IRRITATION    .        .         . 
Symptoms      .... 
Post-mortem  appearances 
Causes,  diagnosis  . 
Prognosis,  treatment 

GENERAL  SPINAL  PARALYSIS 
HYSTERICAL  PARAPLEGIA  . 
REFLEX  PARAPLEGIA 
INFANTILE  PARALYSIS 
SPINAL  HEMORRHAGE 
NON-INFLAMMATORY  SPINAL  SOFTENING 
INDURATION  OF  THE  SPINAL  CORD 
ATROPHY  AND  HYPERTROPHY  OF  THE 

SPINAL  CORD 

TUMOUR  OF  THE  SPINAL  CORD    . 
CONCUSSION  OF  THE  SPINE  . 
COMPRESSION  OF  THE  SPINAL  CORD 
CARIES  OF  THE  VERTEBRAL  COLUMN 


PAGE 

PAGE 

1 

SPINA  BIFIDA     

89 

.»          1 

EPIDEMIC  CEREBRO-SPINAL  MENINGI- 

14 

TIS     

92 

14 

Definition,  synonyms      .         .         . 

92 

21 

Description  of  the  disease 

93 

22 

Special  symptoms  .... 

96 

22 

Complications,    duration,   termina- 

tion     

103 

.       23 

Mode  of  death,  diagnosis        . 

104 

23 

Prognosis,  morbid  anatomy     . 

105 

32 

History  and  geographical  distribu- 

34 

tion    . 

107 

.       35 

Etiology         

110 

38 

Nature  

114 

38 

Treatment     

116 

.       42 

Bibliography           .... 

118 

.       42 

NEURITIS  AND  NEUROMA    . 

120 

.       43 

Neuritis          

120 

.       43 

Neuroma        

122 

43 

131 

.'       52 

Definition,  synonyms      .         .         . 

131 

.       53 

Clinical  history  and  symptoms 

131 

.       54 

Varieties        ..... 

133 

.       56 

Complications         .... 

148 

CO 

Diagnosis       

153 

•       oo 

CO 

Prognosis       

154 

58 

/»•? 

Pathology  and  etiology  . 

155 

b7 

,'W 

Treatment     ..... 

157 

•             UO 

.       69 

LOCAL  PARALYSIS  FROM  NERVE  DIS- 

EASE           

167 

.       71 

General  history      .... 

167 

.       73 

Varieties        ..... 

170 

.       74 

Duration         ..... 

173 

.       78 

Prognosis,  treatment 

174 

.       82 

LOCAL  SPASMS   

178 

TORTICOLLIS      

187 

a      84 

Definition,  synonyms,  causes  . 

187 

85 

Symptoms      

188 

B 

190 

.       85 

Pathology       ..... 

191 

85 

Prognosis        ..... 

191 

.       87 

Treatment      ..... 

192 

.       87 

LOCAL  ANESTHESIA    .... 

193 

.       88 

INDEX        

197 

DISEASES 


OF  THE 


SPINE  AND  OF  THE  NERVES. 


i. 

DISEASES  OF  THE  SPINAL  CORD. 

BY  C.  B.  RADCLIFFE,  M.D.,  F.R.C.P. 

A.    PRELIMINARY  REMARKS. 

BEFORE  proceeding  to  cope  with  the  intricate  and  difficult  patho- 
logical topics  which  form  the  subject  of  the  present  article,  it  appears 
to  be  expedient  to  glance  at  some  points  in  the  physiology  of  the 
spinal  cord,  and  also  to  try  and  ascertain  the  true  significance  of  pain, 
spasm,  and  certain  symptoms  analogous  to  pain  and  spasm,  which 
figure  conspicuously  in  the  histories  of  spinal  maladies;  for  if  these 
matters  be  not  disposed  of  as  preliminaries  now,  they  will  prove  to 
be  the  cause  of  frequent  and  distracting  digressions  afterwards. 

1.  A  glance  at  some  points  in  the  physiology  of  the  spinal  cord. — The 
result  of  recent  researches  has  been  to  establish  in  the  fullest  manner 
the  truth  of  Sir  Charles  Bell's  great  discovery,  that  the  posterior  roots 
of  the  spinal  nerves  are  devoted  to  sensation  only,  and  the  anterior 
roots  to  motion  only.  In  one  article,  at  least,  the  creed  of  to-day  is 
the  same  as  that  of  yesterday :  and  it  is  some  comfort  to  have  it  so, 
for  in  many  other  articles  faith  is  not  a  little  shaken  by  the  changes 
of  belief  which- are  now  found  to  be  necessary. 

The  view  once  held  that  the  posterior  columns  of  the  spinal  cord 
are  made  up  of  bundles  of  fibres  passing  from  the  posterior  roots  of 
the  spinal  nerves  to  the  sensorium  has  proved  to  be  untenable. 
Transverse  division  of  these  columns  produces  in  the  parts  behind 
the  section,  not  numbness,  as  it  would  do  if  these  columns  were  simply 
the  continuation  of  the  posterior  roots  of  the  spinal  nerves,  but  hy- 
pe rassthesi  a ;  and  the  pain  resulting  from  the  section  is  found  to  b<3 
due,  not  to  any  sensitiveness  in  the  columns  themselves,  but  to  the 
irritation  having  extended  to  the  posterior  roots  of  the  spinal  nerves. 
Transverse  division  of  these  columns  produces  in  the  parts  behind  the 
section,  not  paralysis,  but  loss  of  co-ordinating  power,  such  as  is  seen 
in  locomotor  ataxy.  Moreover,  the  researches  of  Mr.  Lockhart  Clarke 
1 


2  DISEASES    OF    THE    SPINAL    CORD. 

prove  very  clearly  that  the  filaments,  comparatively  few  in  number, 
which  go  from  the  posterior  roots  of  the  spinal  nerves  to  the  poste- 
rior columns  of  the  cord,  do  not  end  in  those  columns,  but  pass 
through  them  to  the  part  to  which  the  other  and  more  numerous 
filaments  composing  the  roots  pass  directly — that  is,  to  the  central 
gray  matter  of  the  cord;  and  thus  it  is  not  difficult  to  see  why  the 
posterior  columns  can  be  cut  across  without  benumbing  the  parts 
behind  the  section — why  a  result  should  follow  which  would  not  be 
possible  if  those  columns  were  the  continuation  of  the  posterior  roots 
of  the  spinal  cord. 

All  that  has  been  said  of  the  posterior  columns  of  the  cord  appears 
to  apply  equally  to  the  restiforrn  bodies — to  the  bodies  which  form  the 
chief  connection  between  these  columns  and  the  cerebellum,  and  not  to 
those  bodies  only,  but  also  to  the  small  posterior  pyramids  of  the  me- 
dulla oblongata,  which  pyramids  lie  between  the  restiform  bodies  pos- 
teriorly. The  connection  between  the  cerebellum  and  the  posterior 
columns  of  the  spinal  cord,  which  is  made  by  means  of  the  restiform 
bodies,  is  indeed  such  as  to  make  it  not  improbable  that  the  posterior 
columns  perform  for  the  cerebellum  a  similar  office  to  that  which  is 
performed  for  the  cerebrum  by  the  anterior  columns,  or,  in  other 
words,  that  the  posterior  columns  do  for  the  involuntary  movements 
of  co-ordination  what  appears  to  be  clone  for  voluntary  movements  by 
the  anterior  columns. 

The  anterior  columns  of  the  spinal  cord  have,  without  doubt,  a 
special  connection  with  the  anterior  roots  of  the  spinal  nerves,  and  an 
all-important  part  to  play  in  voluntary  movement;  and  yet  this  cannot 
be  said  of  them,  as  was  formerly  supposed,  in  every  part  of  their 
course.  The  power  of  voluntary  movement  on  the  same  side  of  the 
body,  in  the  muscles  behind  the  section,  is  altogether  destroyed  when 
one  of  the  anterior  columns  is  cut  across,  unless  the  cut  be  in  the  part 
which  lies  immediately  below  the  anterior  pyramid  of  the  medulla 
oblongata;  and  the  same  result  happens  when  the  adjoining  lateral 
column  is  cut  across  where  it  lies  side  by  side  with  that  part  of  the 
anterior  column  which  may  be  cut  across  without  giving  rise  to  para- 
lysis. It  is  plain,  in  fact,  that  in  the  uppermost  part  of  their  course 
the  anterior  columns  have  not  that  intimate  connection  with  the  an- 
terior roots  of  the  spinal  nerves,  and  that  all-important  part  to  play 
in  voluntary  movement,  which  they  evidently  have  everywhere  else. 
And  it  is  also  plain  that  the  anterior  columns  have  somewhat  to  do 
with  sensation  as  well  as  with  voluntary  motion,  for  it  is  a  fact  that  a 
certain  degree  of  numbness  is  always  produced  by  the  injuries  which 
give  rise  to  paralysis. 

A  transverse  section  of  one  of  the  anterior  pyramids  of  the  medulla 
oblongata  in  any  part  of  its  course  annihilates  all  power  of  voluntary 
movement  in  the  muscles  behind  the  section  on  the  opposite  side  of  the 
body;  and  thus  it  is  plain,  not  only  that  each  pyramid  contains  very 
many,  if  not  all,  the  conductors  concerned  in  carrying  the  orders  of 
the  will  to  the  muscles  of  the  opposite  side  of  the  body,  but  also  that 
the  conductors  which  are  collected  in  one  pyramid  decussate  with 
those  collected  in  the  other  pyramid  at  the  lower  and  not  at  the  upper 


PRELIMINARY    REMARKS. 

boundaries  of  the  pyramids.  If  anaesthesia  be  the  result  of  cutting 
across  the  anterior  pyramids  of  the  medulla  oblongata,  its  amount  is 
too  small  to  be  unequivocal;  and,  in  a  word,  all  the  evidence,  old  and 
new,  goes  to  show  that  these  bodies  are  composed  of  conductors  con- 
cerned in  voluntary  motion  without  any  admixture  of  sensory  con- 
ductors. 

The  office  of  the  lateral  columns  of  the  spinal  cord  is  not  so  clearly 
made  out  as  that  of  the  posterior  and  anterior  columns.  In  the  cervi- 
cal region,  for  a  short  distance  below  the  point  at  which  the  anterior 
pyramids  of  the  medulla  oblongata  intercross,  the  lateral  columns  of 
the  spinal  cord  have  certainly  very  much  to  do  in  transmitting  the 
orders  of  the  will  to  the  muscles;  for,  as  has  just  been  seen  incidentally, 
the  muscles  behind  the  section  on  the  same  side  of  the  body  are  para- 
lyzed by  cutting  one  of  them  across.  In  the  lower  part  of  the  cervical 
region,  and  in  the  dorsal  and  lumbar  regions,  it  is  very  different,  and 
the  difference  is  not  very  clearly  determined.  Here  some  trifling  para- 
lysis may  be  produced  by  dividing  these  columns  transversely,  but 
never  more  than  this.  Here,  indeed,  it  would  seem  that  this  operation 
is  followed  by  a  certain  degree  of  anaesthesia,  and  by  the  same  result, 
as  regards  movement,  as  that  which  follows  transverse  division  of  the 
posterior  columns — that  is,  not  by  paralysis,  but  by  in-coordination. 
A  certain  degree  of  anaesthesia  appears  to  be  a  constant  consequence 
of  cutting  across  the  lateral  columns  in  any  part  of  their  course  ;  and 
herein  would  seem  to  be  an  important  distinction  between  the  lateral 
and  the  posterior  columns,  for,  as  has  been  stated  already,  the  result 
of  cutting  across  the  posterior  columns  is  to  produce  hyperaesthesia, 
not  anaesthesia. 

A  section  of  the  olivary  bodies  is  followed,  not  by  any  marked  degree 
of  paralysis,  or  anaesthesia,  but  by  a  state  of  persistent  spasm  in  many 
muscles  on  the  same  side  of  the  body,  in  the  neck  especially — a  state 
which  may  sometimes  continue  for  days,  weeks,  or  even  months.  It 
is  found,  also,  that  this  strange  result  is  produced  by  irritating  several 
parts  of  the  base  of  the  encephalon,  the  lateral  and  posterior  parts  of 
the  medulla  oblongata  and  pons  Yarolii  especially,  as  well  as  by  irri- 
tating the  olivary  bodies.  These  parts  are  not  very  clearly  defined. 
"  They  seem,"  says  Dr.  Brown-Se*quard,  "  to  be  quite  different  from 
those  employed  in  the  transmission  of  sensitive  impressions,  or  of  the 
orders  of  the  will  to  the  muscles,  at  least  in  the  medulla  oblongata 
and  pons  Varolii.  They  constitute  a  very  large  portion  of  these  two 
organs,  and,  perhaps,  as  much  as  three-fourths  of  the  one  first  named. 
They  are  placed  chiefly  in  the  lateral  and  posterior  columns  of  these 
organs  ;  and  because  many  of  their  fibres  do  not  decussate,  the  spasm 
produced  by  irritating  them  is  on  the  same  side  of  the  body." 

Instead  of  being  merely  a  nerve  centre — the  special  centre  of  Mar- 
shall Hall's  exci to- motor  system  of  nerves — there  is  now  reason  to 
believe  (as  Dr.  Brown-Se*quard  has  so  clearly  shown),  that  the  gray 
substance  of  the  spinal  cord  is  an  important  conductor  of  sensory  and 
motor  impressions.  Paralysis  without  loss  of  sensation  on  the  same 
side  of  the  body,  loss  of  sensation  without  paralysis  on  the  other  side 
of  the  body,  are  the  strange  results  of  cutting  across  one  lateral  half 


4  DISEASES    OF    THE    SPINAL    CORD. 

of  the  gray  substance  of  the  spinal  cord  :  anaesthesia  on  both  sides  of 
the  body,  paralysis  on  neither  side,  are  the  equally  strange  results  of 
making  a  vertical  section  midway  between  the  two  lateral  halves: 
these  are  the  two  great  facts  which,  when  properly  interpreted,  furnish 
the  reasons  for  believing,  not  only  that  there  are  sensorial  and  voli- 
tional conductors  in  the  gray  substance  of  the  cord,  but  also  that  thesa 
two  forms  of  conductors  follow  a  different  and  definite  course.  Nor  is 
it  difficult  to  see  how  this  may  be.  Let  the  course  of  the  conductors 
in  connection  with  the  anterior  and  posterior  roots  of  a  pair  of  spinal 
nerves  be  what  is  represented  in  the  following  diagram — a  b  being 
the  motor  conductor  descending  to  the  right,  and  a'  br  the  correspond- 
ing conductor  descending  to  the  left;  c  d  being  the  sensory  conductor 
ascending  from  the  left,  and  cr  d'  the  corresponding  conductor  ascend- 
ing from  the  right — and  very  little  reflection  will  serve  to  supply  the 
demonstration  wanting.  With  the  sensory  and  motor  conductors 


arranged  in  this  manner,  it  is  plain  that  a  cut  across  the  right  lateral 
half  of  the  gray  substance — a  lesion  indicated  in  the  diagram  by  the 
line  A  B — must  destroy  the  continuity  of  the  motor  conductor  a  6,  and 
of  the  sensory  conductor  c  d,  and  leave  untouched  the  motor  conductor 
a'  &',  and  the  sensory  conductor  c'  d' — must  bring  about,  that  is  to  say, 
what  has  been  seen  to  happen  in  the  first  of  the  two  experiments  under 
consideration ;  namely,  preservation  of  sensation  with  Joss  of  motion 
on  the  side  of  the  lesion,  and  preservation  of  motion  with  loss  of  sen- 
sation on  the  opposite  side.  Again,  with  the  sensory  and  motor  con- 
ductors arranged  in  this  manner,  it  is  plain  that  a  longitudinal  section 
of  the  gray  substance  of  the  cord  midway  between  the  two  lateral 
halves — a  lesion  indicated  in  the  diagram  by  the  line  c  A  D — must 
leave  the  motor  conductors  a  b  and  a'  bf  untouched,  and  cut  across  the 
sensory  conductors  c  d  and  cf  d'  at  their  point  of  decussation — must 
bring  about  what  happens  in  the  second  of  these  two  experiments, 
viz.,  numbness  on  both  sides  of  the  body,  and  paralysis  on  neither  side. 
In  saying  that  paralysis  without  loss  of  sensation,  on  the  same  side 
of  the  body,  and  loss  of  sensation  without  paralysis,  on  the  other  side 
of  the  body,  is  produced  by  cutting  across  a  lateral  half  of  the  spinal 
cord,  all  is  not  said  that  has  to  be  said.  In  such  a  case  there  is,  in 
addition,  increased  temperature  and  sensibility  on  the  side  on  which 
sensation  is  preserved,  and  diminished  temperature  on  the  side  on 


PRELIMINARY    REMARKS.  5 

which  sensation  is  lost,  especially  if  the  section  be  made  high  up  near 
the  medulla  oblongata.  It  would  seem,  in  fact,  that  the  injury  has 
acted  on  the  vaso-motor  nerves  contained  in  the  cord  as  well  as  upon, 
the  common  motor  and  sensory  nerves,  causing  paralysis  of  vaso-motor 
nerves  on  the  side  on  which  there  is  increased  temperature  and  sensi- 
bility, and  irritation  of  vaso-motor  nerves  on  the  side  on  which  there 
is  diminished  temperature  and  anaesthesia.  At  any  rate  this  mode  of 
explanation  is  neither  impossible  nor  improbable.  The  experiments 
of  Professor  Claude  Bernard,  Dr.  Brovvn-Sequard,  and  others  upon  the 
cervical  sympathetic,  prove  that  when  this  nerve  is  paralyzed  by 
dividing  it,  a  state  of  hypersemia,  of  which  the  most  conspicuous  signs 
are  a  bloodshot  state  of  the  conjunctiva  and  of  the  lining  membrane 
of  the  nostril  and  ear,  with  a  contracted  pupil,  and  with  increased 
temperature,  is  at  once  set  up  on  the  same  side  of  the  head :  and  also 
that  when  the  end  of  the  divided  nerve  which  is  separated  from  the 
cord  is  irritated,  the  immediate  result  is  dilatation  of  the  pupil,  with 
an  almost  complete  blanching  and  cooling  of  the  parts  which  were 
bloodshot  aud  warm  a  moment  before.  The  vessels  in  these  parts  evi- 
dently relax  and  receive  more  blood  when  their  nerves  are  paralyzed, 
and  contract  and  receive  less  blood  where  their  nerves  are  irritated  ; 
and  the  increased  temperature  and  sensibility  which  happens  in  the 
one  case,  and  the  diminished  temperature  and  sensibility  which  happens 
in  the  other  case,  are  nothing  more  than  the  natural  consequences'of  the 
increased  or  diminished  quantity  of  blood  in  the  parts  in  each  case  re- 
spectively. All  this  is  plain  enough.  Moreover,  there  are  other  facts 
which  go  to  show  that  phenomena  in  every  way  analogous  to  those  which 
result  from  paralysis  or  irritation  of  the  cervical  sympathetic  are  pro- 
duced by  paralyzing  or  irritating  the  vaso-motor  nerves  in  other 
parts.  There  is,  therefore,  no  reason  why  it  may  not  be  inferred  that 
the  increased  temperature  and  sensibility  of  one  side  of  the  body,  and 
the  diminished  temperature  of  the  other  side,  which  happen  when  a 
lateral  half  of  the  spinal  cord  is  cut  across,  are  the  result  of  vaso-motor 
nerves  being  paralyzed  in  the  one  case  and  irritated  in  the  other  case. 
Nay,  such  an  assumption  is  well-nigh  inevitable,  for  the  structural  con- 
nection between  the  spinal  and  sympathetic  systems  of  nerves  is  such 
as  to  make  it  scarcely  possible  to  believe  that  a  lateral  half  of  the  cord 
can  be  cut  across  without  paralyzing  and  irritating  vaso-motor  nerves. 
Above  and  below  the  decussation  of  the  anterior  pyramids  of  the 
medulla  oblongata  the  conductors  which  have  to  do  with  sensation 
and  voluntary  motion  are  arranged  differently  in  the  spinal  cord. 
Above  this  point,  the  sensorial  and  volitional  conductors  belonging  to 
one  side  of  the  body  lie  together  in  the  same  lateral  half  of  the  cord, 
and  this  half  is  that  which  appears  to  belong,  not  to  the  same  side  of 
the  body,  but  to  the  opposite  side ;  at  this  point,  the  volitional  con- 
ductors separate  from  the  sensorial  and  pursue  a  different  course  to 
what  is  the  common  destination  of  both  conductors  alike,  the  voli- 
tional conductors  crossing  over  at  once  and  in  a  body  to  the  other  side 
of  the  cord  and  passing  down  this  side  until  each  one  reaches  the  par- 
ticular anterior  root  at  which  it  emerges,  the  sensorial  conductors 
passing  down  the  same  side  of  the  cord  and  not  crossing  over  to  the 


6  DISEASES    OF    THE    SPINAL    CORD. 

other  side  (where  they  rejoin  the  volitional  conductors)  until  they 
arrive  at  the  level  of  the  particular  posterior  roots  with  which  they 
are  connected.  In  other  words,  thesensorial  and  volitional  conductors 
of  the  two  sides  of  the  body  decussate,  both  of  them,  in  the  spinal  cord, 
but  not  in  the  same  place,  the  decussation  of  the  volitional  conductors 
being  confined  to  the  narrow  path  where  the  anterior  pyramids  of  the 
medulla  oblongata  intercross,  the  decussation  of  the  sensorial  con- 
ductors being  all  along  the  spinal  cord  from  one  end  to  the  other. 
Higher  up  or  lower  down  than  the  narrow  path  which  has  been  indi- 
cated, there  appears  to  be  no  intercrossing  whatever  of  volitional  con- 
ductors. 

All  the  forms  of  sensorial  conductors — those  which  take  cognizance 
of  touch,  pain,  tickling,  temperature,  and  the  rest — appear  to  follow 
the  same  course  in  the  cord,  those  of  the  two  sides  decussating  along 
the  whole  length  of  the  cord  at  the  level  of  their  entrance  or  there- 
abouts, and  ascending  to  the  sensorium  in  the  opposite  half  of  the 
cord  to  that  into  which  they  first  pass  from  the  posterior  roots ;  but 
all  the  forms  of  motor  conductors  do  not  follow  the  course  of  the 
volitional  conductors.  Below  the  point  where  the  anterior  pyramids 
of  the  medulla  oblongata  decussate,  all  forms  of  motor  conductors 
alike  seem  to  agree  in  not  decussating:  at  this  point,  the  only  motor 
conductors  which  decussate  would  seem  to  be  the  volitional.  Thus, 
the  increased  temperature  and  sensibility  resulting  from  paralysis  of 
vaso- motor  nerves,  which  is  produced  by  cutting  into  one  side  of  the 
medulla  oblongata,  above  the  decussation  of  the  anterior  pyramids, 
and  the  persistent  spasm  which  follows  irritation  of  the  corpus  olivare 
and  the  neighbouring  parts — which  spasm  points  to  the  presence  there 
of  motor  conductors  whose  function  is  not  yet  clearly  determined  — 
are  on  the  same  side  of  the  body,  and  not  on  the  opposite  side,  as  they 
would  be  if  these  two  kinds  of  motor  conductors  decussated  like  the 
volitional  conductors. 

When  the  continuity  of  the  cord  as  a  conductor  is  entirely  inter- 
rupted by  being  cut,  torn,  compressed,  or  injured  in  any  other  way, 
voluntary  movement  and  sensation  are  immediately  abolished  in  the 
parts  behind  the  injury,  and  at  the  same  time  the  paralyzed  muscles, 
especially  in  the  lower  extremities,  become  much  more  susceptible  to 
reflex  action.  The  increased  susceptibility  to  reflex  action  is  devel- 
oped immediately,  or  all  but  immediately,  and  it  may  continue  with 
little  change  for  days,  weeks,  or  even  months — a  fact  which  does  not 
appear  to  be  very  intelligible  on  the  current  view  of  muscular  action, 
but  a  fact  nevertheless.  The  higher  the  seat  of  injury  to  the  cord, 
the  higher  must  be  the  level  to  which  the  paralysis  reaches,  and  (if 
the  respiratory  muscles  be  affected  at  all)  the  greater  the  interference 
with  the  breathing,  and,  as  may  be  easily  understood,  it  is  not  difficult 
to  form  a  tolerably  correct  diagnosis  of  the  locality  of  the  injury  by 
taking  these  variations  into  consideration.  If  the  injury  be  at  the 
upper  limit  of  the  sacral  region  of  the  cord,  the  muscles  of  the  bladder 
and  anus  will  be  paralyzed,  and  so  will  the  muscles  of  the  lower  ex- 
tremities, with  the  exception  of  those  which  are  supplied  by  the  ante- 
rior crural  and  obturator  nerves  (the  psoas,  iliacus,  sartorius,  pecti- 


PRELIMINARY    REMARKS.  7 

neus,  adductor  longus,  a.  magnus,  a.  brevis,  obturator  externus,  vastus 
externus,  v.  internus,  rectus  femoris,  &c.),  which  nerves  come  off  from 
the  second,  third,  and  fourth  lumbar  pairs  of  spinal  nerves.  If  the 
injury  be  very  low  down  in  the  sacral  canal,  the  compressor  urethras 
and  the  accelerator  urinae,  as  well  as  the  sphincter  ani,  will  be  para- 
lyzed, but  not  the  muscles  of  the  legs;  for  the  nerves  of  the  three 
muscles,  specified  by  name,  come  off  almost  from  the  extreme  end  of 
the  cord,  and  below  those  which  go  to  form  the  great  sciatic.  When 
the  injury  to  the  cord  is  higher  up  in  the  cord,  in  addition  to  the  loss 
of  voluntary  power  in  the  lower  extremities  and  in  the  bladder  and 
anus,  the  respiratory  muscles  will  be  more  or  less  paralyzed.  If  the 
injury  be  at  the  upper  limit  of  the  lumbar  region,  the  lateral  muscular 
walls  of  the  abdomen  will  be  paralyzed,  and  so  will  all  the  muscles 
of  the  lower  extremities,  and  one  effect  of  the  paralysis  of  the  abdomi- 
nal walls  will  be  to  compromise  greatly  the  expiratory  movements  of 
respiration.  If  the  injury  be  high  enough  to  paralyze  intercostal 
muscles,  inspiration  will  be  interfered  with  as  well  as  expiration,  and 
the  degree  of  interference  will  be  in  proportion  to  the  number  of  in- 
tercostal muscles  implicated.  If  the  injury  be  low  down  in  the  cervi- 
cal region,  all  the  intercostals  will  be  paralyzed,  and  so  will  the  mus- 
cles of  the  upper  extremities,  except  those  of  the  shoulders,  which 
receive  their  nerves  from  higher  portions  of  the  cervical  region.  If 
the  injury  be  at  or  above  the  middle  of  the  cervical  region — at  or 
above  the  level  of  the  fourth  cervical  pair  of  spinal  nerves — death 
will  at  once  result  from  the  suspension  of  all  inspiratory  movements. 
In  this  latter  case  it  is  customary  to  ascribe  the  stoppage  of  breathing 
to  paralysis  of  the  nerve  which  supplies  the  diaphragm, — that  is,  the 
phrenic;  but  this  explanation  does  not  go  far  enough.  The  injury 
which  paralyzes  the  diaphragm  paralyzes  the  scaleni,  the  intercostales, 
and  the  serrati  magni,  which  muscles  elevate  the  ribs  in  ordinary 
respiration,  and  in  so  doing  play  a  part  which  is  scarcely  less  import- 
ant than  that  played  by  the  diaphragm;  and  not  only  so,  but  it  para- 
lyzes also  the  greater  number  of  those  accessory  respiratory  muscles 
which,  acting  upon  and  from  the  shoulders,  come  to  the  rescue  when 
a  great  effort  at  inspiration  is  necessary,  and  produce  additional  ex- 
pansion in  the  upper  part  of  the  chest.  Not  only  is  there  a  great 
difference  between  calm  respiration  and  forced  respiration,  but  there 
is  a  great  difference  also  between  the  respiration  of  males  and  that  of 
females.  "In  males,"  says  Dr.  Hutchinson,  "the  abdomen  first  bulges 
outwards,  and  the  ribs  and  sternum  nearest  to  the  abdomen  quickly 
follow  this  movement,  until  the  motion,  like  a  wave,  is  lost  over  the 
thoracic  region.  In  females  the  breathing  commences  with  a  gentle 
heaving  of  the  upper  part  of  the  thorax,  more  or  less  apparent  accord- 
ing to  the  fulness  of  the  mammaa,  and  with  some  slight  elevation  of 
the  shoulders ;  and  this  movement  of  expansion  spreads  from  rib  to 
rib  in  a  downward  direction,  and  any  bulging  of  the  abdomen  from 
the  descent  of  the  diaphragm  is  distinctly  after  this  heaving  of  the 
lateral  walls  of  the  chest,  not  before  it."  In  females  also  this  bulging 
of  the  abdomen  is  so  inconsiderable  that  the  number  of  respirations 
cannot  be  counted  by  the  hand  resting  on  that  region  as  it  can  be  in 


8  DISEASES    OF    THE    SPIRAL    CORD. 

the  male.  In  calm  breathing,  in  fact,  the  diaphragm  does  more  and 
the  ribs  do  less  in  males  than  in  females,  and  this  difference  is  so  real 
that,  for  the  sake  of  distinction,  calm  breathing  may  be  spoken  of  as 
diaphragmatic  in  males,  and  as  costal  in  females.  This  difference, 
indeed,  is  such  that  respiratory  movements  which  are  healthy  in 
women  are  morbid  in  men ;  and  vice  versa,  that  movements  which  are 
healthy  in  men  are  morbid  in  women.  "In  forced  breathing,"  Dr. 
Hutchinson  again  says,  "the  greatest  enlargement  of  the  thoracic 
cavity  in  both  sexes  is  made  by  the  ribs  and  not  by  the  diaphragm, 
as  is  generally  believed ;"  and  that  this  statement  expresses  what 
really  happens,  appears  to  be  evident  in  the  fact  that  in  such  breath- 
ing the  hollow  at  the  pit  of  the  stomach,  instead  of  being  filled  out 
and  protruded,  as  it  must  be  if  the  diaphragm  descended  in  any 
marked  degree,  is  actually  drawn  in  and  depressed.  In  forced  breath- 
ing, indeed,  the  costal  inspiration  of  women  becomes  more  costal,  and 
the  diaphragmatic  inspiration  of  men  changes  from  this  form  to  the 
costal.  It  is  certain,  however,  that  there  may  be  forced  diaphragmatic 
breathing  as  well  as  forced  costal  breathing,  and  that  the  one  may  be 
made  to  take  the  place  of  the  other  by  an  easy  effort  of  the  will,  or 
by  changes  of  position  which  interfere  with  the  action  of  the  dia- 
phragm on  the  one  hand,  or  of  the  ribs  on  the  other.  There  is,  in- 
deed, no  difficulty  in  understanding  why  diseases  which  interfere  with 
the  action  of  the  diaphragm  or  ribs  should  make  the  breathing  costal 
or  diaphragmatic,  as  the  case  may  be.  £s  regards  the  expiratory 
movements  of  respiration  there  is  little  to  say.  In  tranquil  breathing, 
in  males  and  in  females  alike,  expiration  is  performed  by  the  relaxa- 
tion of  the  diaphragm  allowing  the  abdominal  viscera  to  press  up  into 
the  position  from  which  they  had  been  depressed  in  inspiration  by 
the  contraction  of  this  muscle,  by  the  relaxation  of  the  costal  muscles 
allowing  the  ribs  to  spring  back  into  the  position  from  which  they 
had  been  pulled  up  in  inspiration  by  the  contraction  of  these  muscles, 
and  by  the  resiliency  of  the  air-passages  themselves.  In  forced  expi- 
ration the  lateral  and  inferior  muscular  walls  of  the  abdomen  will 
help  to  empty  the  chest  by  pulling  down  the  ribs  and  by  contracting 
upon  the  abdominal  viscera,  so  as  to  cause  them  to  push  up  the  dia- 
phragm more  effectually.  It  is  easy,  indeed,  to  see  how  a  lesion  of 
the  spinal  cord  which  paralyzes  the  lateral  and  inferior  abdominal 
walls  must  interfere  with  the  movements  of  expiration,  and  especially 
with  such  violent  movements  as  coughing  or  sneezing.  In  a  word, 
the  whole  case  of  the  respiratory  movements  is  one  which  makes  it 
impossible  to  continue  in  the  belief  that  the  one  reason  why  the  divi- 
sion of  the  cord  at  or  above  the  origin  of  the  phrenic  nerve  proves 
fatal,  is  because  the  diaphragm  is  paralyzed ;  for  the  plain  fact  is,  that 
the  injury  which  paralyzes  the  diaphragm  paralyzes  the  muscles 
which  elevate  the  ribs,  both  ordinary  and  extraordinary,  and  so  puts 
an  end  to  movements  which  are  quite  as  important  as  those  of  the 
diaphragm,  if  not  more  so,  in  carrying  on  respiration.  Of  the  other 
phenomena  which  may  be  present  when  the  injury  which  interrupts 
the  continuity  of  the  cord  as  a  conductor  is  in  the  neck,  but  not  so 
high  as  to  destroy  li'fe  immediately,  and  which  are  not  likely  to  be 


PRELIMINARY    REMARKS.  9 

present  when  the  injury  is  much  below  the  cervical  region,  difficulty 
of  swallowing,  difficulty  in  vocalization,  contraction  of  pupils,  palpita- 
tion, and  priapisrn  appear  to  be  the  most  important. 

In  these  remarks  the  name  of  Dr.  Brown-Se'quard  has  been  men- 
tioned more  than  once,  and  it  might  have  been  mentioned  oftener 
very  easily.  Indeed,  it  is  not  too  much  to  say  that  the  discoveries  of 
this  very  distinguished  physiologist  mark  a  new  epoch  in  the  physi- 
ology and  pathology  of  the  spinal  cord. 

2.  On  the  practical  significance  of  pain  and  spasm,  and  of  certain 
other  symptoms  more  or  less  akin  to  pain  and  spasm. — Have  these 
symptoms  to  do  with  inflammation,  or  with  a  state  which,  though 
not  unfrequently  passing  into  inflammation,  is  in  reality  diametrically 
opposed  to  inflammation?  This  is  the  question  to  which  I  propose 
now  to  seek  the  answer,  first,  in  relation  to  pain  and  the  symptoms 
akin  to  pain,  and,  secondly,  in  relation  to  spasm  and  the  symptoms  akin 
to  spasm. 

(a)  On  the  practical  significance  of  pain  and  the  symptoms  akin 
to  pain. — There  are  some  points  in  the  history  of  common  neuralgia — 
the  beginning  and  ending  of  the  paroxysm  periodically  at  a  given 
time,  the  association  of  the  pain  with  rigors,  the  frequent  ending  of 
the  pain  in  an  obscure  fit  of  feverishness,  and  others — which  are  cal- 
culated to  suggest  some  relationship  between  this  disorder  and  ague. 
It  would  seem,  indeed,  especially  in  that  form  of  neuralgia  which  is 
met  with  in  agueish  districts,  as  if  the  neuralgia  and  the  rigors  were 
companion  symptoms— as  if  there  was  some  connection  between  the 
pain  and  a  depressed  state  of  the  circulation,  such  as  is  met  with  in 
the  cold  stage  of  ague.  There  is  also  some  reason  to  believe  that 
neuralgia  is  antagonized  rather  than  favoured  by  inflammation  and 
fever.  It  is  no  uncommon  thing  for  the  history  of  facial  neuralgia  or 
tic  douloureux  to  be  this:  first,  neuralgia,  without  local  tenderness 
and  swelling,  and  redness,  and  with  frequent  chills  and  shivers,  and 
a  decidedly  depressed  state  of  the  circulation ;  afterwards,  cessation 
of  neuralgia,  cessation  of  chills  and  shivers,  with  local  tenderness, 
redness,  and  swelling,  and  with  some  slight  feverish  reaction.  What 
I  have  experienced  in  my  own  person,  as  well  as  what  I  have  wit- 
nessed in  others,  enables  me  to  speak  with  all  confidence  upon  this 
point.  It  is  also  the  rule,  rather  than  the  exception,  for  the  neuralgic 
pain  of  toothache  to  come  to  an  end  when  the  face  becomes  swollen 
and  inflamed;  and  it  does  not  seem  to  be  otherwise  with  the  stabbing 
neuralgic  pains  which  so  generally  precede  the  inflammatory  eruption 
of  herpes,  for  it  is  usual  for  these  pains  to  subside  concurrently  with 
the  development  of  the  eruption.  Nay,  I  know  of  several  cases  of 
sciatica,  in  which  the  relief  to  the  neuralgic  pain  was  coincident  with 
the  development  of  a  tenderness  which  seemed  to  betoken  neuritis  at 
one  or  more  points  in  the  course  of  the  painful  nerve,  and  in  which, 
after  this  change,  the  patient  was  comparatively  free  from  pain  so  long 
as  the  larne  limb  was  kept  still  and  let  alone.  With  respect  to  neu- 
ralgia, in  all  its  manifold  forms,  indeed  one  thing  is  certain,  and  this 
is,  not  only  that  neuritis  is  not  necessary  to  its  production,  but  also  that 
this  form  of  inflammation  is  at  most  a  very  exceptional  complication. 


10  DISEASES    OF    THE    SPINAL    CORD. 

Nor  is  a  different  conclusion  to  be  drawn  from  the  history  of  rheu- 
matic and  gouty  pain. 

In  acute  rheumatism  it  is  generally  found  that  the  pains  which  had 
been  torturing  the  patient  for  days,  or  weeks,  or  months  previously, 
preventing  him  from  being  at  ease  in  the  daytime,  and  causing  him 
to  toss  about  in  sleepless  misery  at  night,  come  to  an  end  when  the 
feverish  reaction  and  local  inflammation  of  the  fully-formed  disorder 
make  their  appearance.  After  this,  the  joints  are  tender  enough;  but 
if  the  patient  keep  as  still  as  he  is  very  likely  to  do  under  the  circum- 
stances, he  is  comparatively  or  actually  at  ease  so  far  as  his  old  rheu- 
matic pains  are  concerned.  Or,  if  it  be  otherwise,  the  pains  will 
generally  be  found  to  be  in  apart  in  which  the  signs  of  rheumatic 
inflammations  are  imperfectly  established  or  absent,  or  else  at  a  time 
when  there  is  a  decided  remission  in  the  feverish  reaction — an  event 
which  happens  more  frequently  in  this  disorder  than  is  commonly 
supposed. 

And  certainly  it  is  simply  impossible  to  look  upon  the  local  inflam- 
mation of  gout  as  essential  to  the  racking  pain  of  this  disorder. 
"About  two  o'clock  in  the  morning,"  says  Sydenham,  who  knew  full 
well  from  personal  experience  what  he  ought  to  say,  "the  patient  is 
awakened  by  a  severe  pain  in  the  great  toe,  or  more  rarely,  in  the 
heel,  ankle,  or  instep.  The  pain  is  like  that  of  dislocation,  and  yet 
the  parts  feel  as  if  cold  water  were  being  poured  over  them.  Then 
follow  chills  and  shiverings,  and  a  little  fever.  The  pain,  which  was 
at  first  moderate,  becomes  more  intense;  and  with  its  intensity  the 
chills  and  shivers  increase."  After  tossing  about  in  agony  for  four  or 
five  hours,  often  till  near  daybreak,  the  patient  suddenly  finds  relief, 
and  falls  asleep.  Before  falling  asleep,  the  only  visible  change  in  the 
tortured  part  is  some  swelling  in  the  veins;  on  waking  in  the  morn- 
ing the  part  has  become  swollen,  shining,  red,  tender  beyond  measure, 
and  more  or  less  painful,  but  painful  only  to  a  degree  which  is  as 
nothing  in  comparison  with  the  torture  of  the  night  past.  It  seems, 
indeed,  as  if  the  pain  which  now  exists  may  in  great  measure  be  re- 
ferred to  the  mere  tension  and  stretching  of  the  inflamed  ligaments, 
for  it  may  be  relieved,  or  even  removed,  by  judiciously  applying  sup- 
port to  the  toe  and  sole  of  the  foot.  On  the  night  following,  and  not 
unfrequently  for  the  next  three  or  four  nights,  the  sharp  pain  may 
return,  reappearing  and  disappearing  suddenly,  or  almost  suddenly, 
and  resulting  in  the  development  of  additional  inflammatory  swelling 
in  the  interval  between  falling  asleep  and  waking  in  the  morning. 
The  pain  in  these  relapses,  like  the  pain  in  the  first  attack,  is  accom- 
panied by  chills  and  shivers,  and  by  the  most  distressing  irritability 
and  excitability  ;  but,  until  unequivocal  signs  of  inflammation  are  de- 
veloped in  it,  the  painful  part  is  not  tender  in  the  true  sense  of  the 
word.  The  inflammation,  moreover,  is  attended  by  no  fever,  or  by 
very  little ;  or  if  it  be  otherwise,  as  it  is  occasionally,  the  inflammation 
runs  higher  than  usual,  and  the  characteristic  pain  is  less  urgent  than 
usual.  Dr.  Garrod  points  out  this  latter  fact  in  his  excellent  work  on 
gout.  From  its  history,  then,  it  would  seem  as  if  the  pain  went  hand 
in  hand  with  the  rigors  which  belong  to  the  cold  stage  of  gouty  in- 


PRELIMINARY    REMARKS.  11 

flammation.  It  would  seem  as  if  the  inflammation,  as  inflammation, 
had  little  to  do  with  the  pain ;  for  if  it  were  otherwise  it  is  scarcely  to 
be  supposed  that  the  pain  should  be  least  urgent  in  the  cases  of  gout 
in  which  the  inflammation  is  most  marked,  and  that  the  unequivocal 
signs  of  inflammation  should  make  their  appearance  during  sleep 
without  waking  the  patient.  Nay,  it  would  even  seem,  as  if  the  pain 
were  put  an  end  to  by  the  establishment  of  inflammation — as  if,  in 
fact,  the  pains  were  antagonized  rather  than  favoured  by  the  inflam- 
matory condition.  Moreover,  the  suddenness  with  which  it  begins 
and  ends  in  the  majority  of  cases  must  be  looked  upon  as  a  reason  for 
referring  the  pain  to  the  category  of  neuralgia — a  disorder  with  which, 
as  I  have  already  shown,  inflammation  has  no  necessary  connection. 

There  is  also  reason  to  believe  that  pain  holds  the  same  relation  to 
fever  and  inflammation  in  other  kinds  of  fever  besides  the  rheumatic, 
and  in  other  kinds  of  inflammation  besides  the  gouty. 

The  pain  in  the  back,  often  very  severe,  which  ushers  in  smallpox, 
disappears  before  the  hot  stage  is  fully  established.  It  comes  and  goes 
hand  in  hand  with  the  rigors,  and  it  belongs  to  the  cold  stage  as  evi- 
dently as  do  the  rigors.  And  this  would  seem  to  be  the  case  also  in  other 
fevers ;  for  it  is  the  rule,  and  not  the  exception,  for  the  pains  which 
attend  upon  the  onset  of  these  disorders  to  pass  away  or  to  become 
greatly  mitigated  as  soon  as  the  cold  stage  gives  place  to  the  hot.  Nay, 
it  would  seem  as  if  pain  gave  place  for  the  time  to  what  may  be  called 
artificial  feverishness.  At  any  rate,  I  have  more  than  once  felt  tic 
douloureux  in  my  face  pass  away  as  soon  as  I  could  set  my  blood  in 
brisk  motion  by  violent  bodily  exercise ;  and  on  two  occasions  I  have 
put  a  stop  to  a  sudden  attack  of  lumbago  while  in  the  saddle,  by  a 
practice  which  is  not  unfrequently  adopted  in  such  a  case  in  the  hunt- 
ing-field— that  is,  by  leaning  forwards,  and  beating  the  loins  with  the 
hands  until  the  whole  body  was  aglow,  and  the  perspiration  dropped 
from  the  forehead. 

The  acute  pain  of  a  dislocation  or  sprain — the  pain  to  which  Syden- 
ham  likens  that  of  gout — does  not,  as  a  rule,  remain  after  the  parts 
have  begun  to  be  hot  and  tender  and  swollen ;  and  as  a  rule,  also, 
the  pain  of  idiopathic  inflammation  goes  before,  and  not  along  with, 
the  redness  and  heat  and  swelling.  In  the  idiopathic,  as  well  as  in 
the  traumatic  forms  of  inflammation,  it  would  seem,  indeed,  as  if  the 
pain  were  related  to  the  cold  stage  of  the  disorder,  and  not  to  the  hot. 
Nor  is  a  contrary  conclusion  to  be  drawn  from  the  history  of  those 
cases  in  which  the  pain  continues  after  the  hot  stage  of  the  inflamma- 
tion is  fully  established,  for  in  these  cases  this  persistent  pain  is  evi- 
dently (in  great  measure  at  least)  due  to  the  stretching  of  parts  made 
tender  by  the  inflammation.  Thus,  for  example,  the  pain  which 
remains  after  the  hot  stage  is  fully  established  in  orchitis  and  pleu- 
ritis,  is  at  once  removed  or  relieved  by  means  which  obviate  this 
stretching — in  the  former  case  by  the  free  use  of  the  knife,  in  the 
latter  case  by  the  application  of  a  roller  around  the  chest,  so  as  to 
prevent  the  movement  of  the  ribs  over  the  seat  of  inflammation. 

Even  in  inflammation  of  the  membranes  of  the  brain,  severe  pain 
in  the  head  cannot  be  looked  upon  as  a  symptom  of  this  inflammation. 


12  DISEASES    OF    THE    SPINAL    CORD. 

Three  or  four  years  ago  I  had  a  youth,  in  the  "Westminster  Hospital 
with  well-marked  symptoms  of  acute  cerebral  meningitis.  When  I 
first  saw  him,  he  complained  of  frequent  rigors  and  of  a  constant 
agonizing  pain  in  the  head,  and  at  this  time  his  face  was  pale  and 
perspiring,  his  ears  and  his  head  generally  were  below  the  natural 
temperature,  his  pupils  somewhat  dilated,  and  his  pulse  contracted  and 
feeble.  Eight  hours  afterwards,  when  I  saw  him  the  second  time,  his 
face  was  flushed,  his  head  burning  hot,  his  pupils  contracted,  his  eyes 
ferrety,  his  skin  hot  and  dry,  his  pulse  strong  and  full,  and  fierce  de- 
lirium had  taken  the  place  of  the  pain.  And  this,  so  far  as  my  expe- 
rience goes,  is  the  regular  history  of  pain  in  this  disorder.  It  is  pain 
ceasing,  not  pain  beginning,  as  the  symptoms  of  active  determination 
of  blood  to  the  brain  make  their  appearance.  It  is  pain  in  association 
with  an  anasmic  rather  than  with  a  hyperasmic  condition. 

For  these  among  many  reasons  it  is  that  pain  (with  the  exception 
of  that  form  of  pain  which  is  dependent  on  tenderness,  and  which  is 
accidental  only)  does  not  appear  to  be  a  symptom  of  inflammation  or 
fever.  In  inflammation  or  fever  the  pain  would  seem  to  be  connected 
with  the  cold  stage  preceding  the  hot  stage,  and  not  with  the  hot  stage 
itself — with  a  state  of  capillary  contraction  and  deficiency  of  blood, 
and  not  with  a  state  of  capillary  relaxation  and  excess  of  blood — with 
a  state  of  vaso-motor  irritation,  and  not  with  a  state  of  vaso-motor 
paralysis :  in  other  cases,  the  pain  would  seem  to  have  to  do  with  a 
state  of  circulation  which  is  in  reality  closely  akin  to  that  which  exists 
in  the  cold  stage  of  inflammation  and  fever.  Pain,  however,  must  not 
be  regarded  as  a  symptom  of  inflammation  or  fever  because  it  happens 
to  be  associated  with  the  so-called  cold  stage  of  these  disorders.  In 
point  of  fact,  this  so-called  cold  stage  of  inflammation  or  fever  is  a 
state  which  is  diametrically  opposed  to  the  so-called  hot  stage.  In 
this  cold  stage,  the  vaso-motor  nerves  (and  not  these  nerves  only)  are 
in  a  state  of  irritation,  and,  as  the  result  of  this  irritation,  the  capillaries 
are  contracted  and  bloodless ;  in  the  hot  stage,  on  the  contrary,  the 
vaso-motor  nerves  are  paralyzed,  and,  as  a  result  of  this  paralysis,  the 
capillaries  are  relaxed  and  bloodshot.  Instead  of  being  stages  in  the 
same  process,  the  so-called  cold  stage  and  the  so-called  hot  stage  are 
conditions  diametrically  opposed  to  each  other.  Instead  of  being  stages 
in  the  same  process,  it  would  rather  seem  that  the  hot  stage  has  a 
remedial  relation  to  the  cold  stage — that,  within  certain  limits,  the 
hot  stage  is  the  salutary  refluence  of  a  tide  of  life  which  has  ebbed 
too  low  in  the  cold  stage.  It  is  not  difficult  to  see  that  there  is  an 
intimate  connection  between  the  so-called  cold  stage  and  the  so-called 
hot  stage,  and  that  the  first  may  easily  change  into  the  second.  It  is 
not  difficult  to  see  that  there  must  be  this  relation  between  these  stages  ; 
for  if,  as  there  is  good  reason  to  believe,  irritation  of  vaso-motor  nerves 
may  bring  about  the  cold  stage  by  causing  contraction  of  vessels,  it  is 
easy  to  understand  that  the  paralysis  of  vaso-motor  nerves,  which 
follows  when  this  irritation  is  carried  beyond  a  certain  point,  may 
lead  to  the  hot  stage  by  causing  relaxation  of  vessels.  At  any  rate, 
be  this  as  it  may,  the  plain  fact  would  seem  to  be  that  pain,  with 
the  exception  of  that  form  of  pain  which  is  dependent  on  tender- 


PRELIMINARY    REMARKS.  13 

ness,  is  a  symptom  belonging  to  the  so-called  cold  stage  of  inflam- 
mation and  fever,  or  to  a  state  of  circulation  closely  akin  to  it,  and 
not  to  the  hot  stage  of  inflammation  and  fever,  or  to  a  state  of  circula- 
tion akin  to  it.  Nay,  it  may  even  be  supposed,  and  not  without  some 
show  of  reason,  that  pain  must  be  associated  with  contracted  and 
empty  capillaries;  for,  the  sympathies  of  the  nervous  system  being 
what  they  are,  it  is  not  easy  to  believe  that  the  vaso-motor  nerves  do 
not  participate  in  the  irritation  which  acts  on  the  sensory  nerves,  and 
which,  so  acting,  gives  rise  to  pain. 

And  if  this  be  so — and  this  is  the  practical  conclusion  to  which 
these  remarks  tend — it  follows  that  pain  is  likely  to  be  relieved  by 
measures  which  are  calculated  to  rouse  the  circulation  and  increase  the 
quantity  of  blood  in  the  capillaries  of  the  principal  part,  and  not  by 
those  which  have  a  contrary  action. 

With  regard  to  tingling  and  other  symptoms  which  are  more  or 
less  akin  to  pain  there  is  little  to  say.  Indeed,  all  I  can  say  is  that 
the  history  of  these  symptoms,  so  far  as  it  is  known  to  me,  would 
seem  to  agree  rather  than  to  disagree  with  that  of  pain,  in  connecting 
them  with  a  state  of  irritation,  and  not  with  a  state  of  actual  inflam- 
mation. 

(b)  Of  the  significance  of  spasm  and  the  symptoms  akin  to  spasm. — 
The  violent  and  general  epileptic  form  of  convulsion  which  attends 
upon  death  by  hemorrhage  or  suffocation  is  associated  with  a  defective 
and  not  with  an  excessive  supply  of  arterial  blood  to  one  or  other  of 
the  great  nerve-centres.  Nor  is  it  otherwise  with  ordinary  epileptic 
or  epileptiform  convulsion.  The  deathly  paleness  of  the  countenance 
which  precedes  the  convulsion  is,  indeed,  a  plain  proof  that  the  fit 
commences  in  a  state  of  circulation  which  is  the  very  opposite  to  that 
of  active  determination  of  blood  to  the  head,  and  the  strong  pulse 
which  is  usually  perceptible  in  the  arteries  as  the  fit  progresses  is  no 
contradiction  to  this  conclusion.  This  strong  pulse  is  usually  regarded 
as  a  sign  of  arterial  excitement — as  a  proof  that  more  arterial  blood 
is  being  injected  into  the  arteries  at  this  time,  and  that,  on  this  account, 
certain  nervous  centres  are  excited  to  an  unwonted  degree  of  activity ; 
but  the  simple  fact  is,  that  the  strong  pulse  which  is  present  under 
these  circumstances  derives  its  strength,  not  from  arterial  blood,  but 
from  venous.  Black  blood  is  being  pumped  into  the  arteries  at  the 
time,  and  because  black  blood  moves  less  readily  through  the  capil- 
laries than  red  blood,  the  arteries  become  distended  and  the  pulse 
endowed  with  a  counterfeit  power.  The  strong  pulse  in  question  is 
caused  by  the  suffocation  which  is  a  part  of  the  fit;  it  is  a  pulse  of 
black  blood  and  not  of  red,  as  may  easily  be  proved  by  making  an 
opening  into  the  artery;  it  is  nothing  more,  in  fact,  than  the  natural 
pulse  of  suffocation.  Hence,  the  strong  pulse  of  the  epileptic  or  epi- 
leptiform paroxysm  is  no  proof  that  this  form  of  convulsion  is  con- 
nected with  an  excited  condition  of  the  circulation;  on  the  contrary, 
when  rightly  read,  it  points  only  to  the  opposite  conclusion. 

It  would  seem  also  that  convulsion  is  not  associated  with  an  over- 
active  condition  of  the  circulation,  even  in  those  cases  in  which  at  first 
sight  it  might  appear  to  be  so.  In  the  fevers  of  iufaucy  and  early 


14  DISEASES    OF    THE    SPINAL    COKD. 

childhood,  especially  in  the  exanthematous  forms  of  these  disorders, 
convulsion  not  unfrequently  takes  the  place  occupied  by  rigor  in  the 
fevers  of  youth  and  riper  years.  It  occurs  in  the  initial  cold  stage,  or 
else  in  the  last  moments  of  life,  not  in  the  intermediate  hot  stnge. 
Again  in  inflammation  of  the  membranes  of  the  brain,  convulsion, 
when  it  occurs,  is  connected  with  the  cold  stage  before  the  hot  stage, 
or  with  the  cold  stage  after  the  hot  stage,  and  never  with  the  hot  stage 
itself.  Nay,  I  am  disposed  to  think  that  there  is  something  altogether 
uncongenial  between  convulsion  and  a  state  of  febrile  reaction  in  the 
circulation,  for  it  is  a  fact  not  unfrequently  verified  that  fits  of  com- 
mon epilepsy  are  often  suspended  during  the  continuance  of  such 
reaction. 

As  indeed  I  have  endeavoured  to  show  at  length  elsewhere,  especially 
in  the  lectures  which  I  delivered  at  the  Royal  College  of  Physicians, 
in  London  in  1862  (post  8vo.  London :  Churchill  and  Sons),  the 
physiology  and  pathology  of  muscular  action,  so  far  as  I  can  read 
them,  serve  only  to  connect  all  the  varied  forms  of  tremor,  convulsion, 
and  spasm,  with  diminished  and  not  with  increased  activity  of  the 
circulation  ;  and  thus  the  practical  significance  of  spasm  and  the 
symptoms  akin  to  spasm  would  appear  to  be  the  same  as  that  of  pain 
and  the  symptoms  akin  to  pain — namely  this,  that  the  measures 
calculated  to  afford  relief  are  likely  to  be  those  which  will  rouse  the 
circulation  to  greater  activity  and  increase  the  quantity  of  blood  in 
the  capillaries,  and  not  those  which  have  a  contrary  action. 

B.  ON  DISEASES  OF  THE  SPINAL  CORD. 

Under  the  head  of  diseases  of  the  spinal  cord  there  is  no  lack  of 
subjects.  As  of  primary  importance  may  be  mentioned  spinal  menin- 
gitis, myelitis,  spinal  congestion,  tetanus,  and  spinal  irritation  ;  as  of 
secondary  importance,  locomotor  ataxy,  reflex  paraplegia,  infantile 
paralysis,  hysterical  paralysis,  hemorrhage,  white  softening,  in- 
duration, atrophy,  hypertrophy,  tumour,  concussion,  compression, 
vertebral  caries,  spina  bifida,  &c.  I  shall  take  each  of  these  subjects 
in  the  order  in  which  it  has  been  enumerated,  and,  as  far  as  I  can, 
apportion  the  limited  space  at  my  command  (very  limited  for  such  a 
purpose)  so  that  there  may  be  room  for  saying  most  where  most  is 
wanted. 

I.  MENINGITIS. 

Inflammation  of  the  membranes  of  the  spinal  cord  is  usually  asso- 
ciated with  inflammation  of  the  substance  of  the  cord  (myelitis)  or 
with  inflammation  of  the  membranes  of  the  brain,  but  uncomplicated 
cases  do  occur  now  and  then,  and  with  care  it  is  not  difficult  to  dis- 
criminate between  the  symptoms  which  are  essential  to  spinal  menin- 
gitis and  those  which  are  only  accidental. 

1.  SYMPTOMS. — In  order  to  arrive  at  a  knowledge  of  the  symptoms 
of  spinal  meningitis,  I  will  relate  as  a  text  one  of  three  cases  verified 
by  post-mortem  examination  which  have  come  under  my  own  notice, 


MENINGITIS.  15 

and  then  proceed  to  see  wherein  it  agrees  with  or  differs  from  other 
cases  of  the  kind.  I  choose  an  acute  case  rather  than  a  chronic  one, 
for  it  is  only  in  the  acute  form  of  the  disease  that  the  symptoms  are  to 
be  defined  with  certainty. 

Case. — A  lightly-made,  delicate-looking  youth,  nineteen  years  of 
age,  a  cigar-maker  by  trade,  was  admitted  into  one  of  my  wards  in, 
the  Westminster  Hospital  on  the  27th  December,  1864. 

(a)  When  I  saw  him  first — this  was  on  the  day  after  his  admission 
— he  complained  chiefly  of  pain  in  the  back  and  great  general  weak- 
ness and  weariness,  and  expressed  his  belief  that  he  had  got  rheumatic 
fever.  He  was  then  sitting  by  the  fireside,  and  looking  very  ill.  On 
telling  him  that  he  had  better  lie  down,  he  got  up  and  walked  towards 
his  bed,  or  rather  he  attempted  to  do  so,  for  the  first  step  brought  on 
a  severe  pain  in  the  back  and  legs,  with  a  feeling  of  faintness  and  want 
of  breath,  and  he  would  have  fallen  if  assistance  had  not  been  at  hand. 
Very  soon  after  lying  down  he  passed  about  a  quart  of  water  without 
any  difficulty. 

(&)  The  account  he  gives  of  himself  is  this.  A  week  ago,  after 
being  very  tired  by  a  long  walk,  he  was  seized  by  shiverings  and 
sharp  pain  between  the  shoulders.  During  the  next  three  days  he 
was  feverish  and  without  appetite,  but  still  able  to  go  about  and  do  his 
work.  All  this  while,  he  had  very  little  pain,  and  his  nights  were  not 
disturbed.  On  the  night  of  the  fourth  day  from  the  commencement 
of  the  illness  he  was  awakened  by  violent  pain  along  the  whole  course 
of  the  spine  in  the  groins,  and  in  the  right  leg.  Next  day  the  pain 
occurred  several  times  in  paroxysms,  and  was  accompanied  by  a  good 
deal  of  starting  and  jerking  in  the  legs;  and  so  also  on  the  two  days 
following.  On  the  day  before  admission  to  the  hospital  some  difficulty 
in  opening  the  jaw  was  experienced,  and  the  paroxysms  of  pain,  and 
jerking,  and  starting,  had  become  more  frequent  and  urgent.  All  this 
while  the  bowels  and  bladder  acted  properly. 

Dec.  28.  There  is  no  material  change  since  yesterday — not  for  the 
worse,  certainly. 

29^A.  Last  night,  after  three  or  four  hours'  sleep,  the  patient 
awoke  with  very  severe  pain  along  the  spine  and  down  both  legs;  and 
since  that  time  the  pain  has  recurred  several  times.  These  attacks 
are  separated  by  intervals  of  comparative  or  complete  ease,  and 
instead  of  the  jerks  and  starts,  which  went  hand  in  hand  with  it  pre- 
viously, the  pain  is  now  accompanied  with  stiffness  in  the  muscles  of 
the  back  and  legs.  At  the  present  moment  (about  2  P.  M.)  the  head  is 
drawn  back  on  the  pillow,  and  considerable  pain  and  stiffness  in  the 
neck  is  caused  by  moving  it.  Before  making  this  movement  the  pa- 
tient was  free  from  pain  and  stiffness  in  this  region.  Asking  him  to 
try  to  sit  up,  he  attempted  to  do  so,  but  was  stopped  at  once  by  a 
severe  paroxysm  of  pain  along  the  whole  length  of  the  spine  and 
down  the  legs,  and  by  the  muscles  in  the  painful  parts  becoming  stiff. 
The  action  of  the  muscles  produced  in  this  way  arched  the  body  back- 
wards almost  as  much  as  in  ordinary  cases  of  tetanus,  and  at  the  same 
time  pursed  up  the  mouth  and  eyes,  and  gave  a  set  expression  to  the 
features  generally,  so  that  the  patient  for  the  time  had  the  appearance 


16  DISEASES    OF    THE    SPINAL    CORD. 

of  a  person  considerably  older  than  himself.  The  pain  went  oft*  in  a 
few  minutes,  and  soon  afterwards  the  stiffened  muscles  relaxed.  The 
effort  to  move  one  of  the  legs  spontaneously  gave  rise  to  sharp  pain 
in  the  thigh  and  loins,  and  the  limb  became  somewhat  stiffened  in  a 
semi  flexed  position,  and  this  state  of  things  did  not  pass  off  for  several 
minutes;  and  passive  movement  produced  the  same  result.  There 
was  no  numbness:  on  the  contrary,  the  condition  of  the  skin  as  to 
sensation  everywhere,  as  judged  by  pricking  and  pinching  and  by 
differences  of  temperature,  was  plainly  that  of  slight  over-sensitive- 
ness. Pressure  along  the  spinal  column  failed  to  detect  tenderness 
anywhere,  and  the  result  of  applying  a  sponge  wrung  out  of  hot 
water  was  equally  negative. 

In  the  course  of  the  examination  it  was  evident  that  any  movement 
of  the  body,  or  neck,  or  legs,  active  or  passive,  gave  rise  to  pain  and 
stiffness  in  the  muscles  moveld;  and  also  that  there  was  little  or  no 
pain  or  stiffness  so  long  as  the  patient  kept  quite  still.  It  was  evi- 
dent, in  fact,  that  the  muscles  were  relaxed,  except  perhaps  in  the 
neck,  in  the  intervals  between  the  paroxysms.  The  poor  sufferer  was 
evidently  in  a  great  strait,  dreading  all  movement,  because  he  knew 
full  well  what  the  effect  of  movement  would  be,  and  at  the  same  time 
continually  prompted  by  an  intolerable  feeling  of  unrest  and  fidgeti- 
ness to  wish  to  have  his  position  changed  in  a  way  which  he  could  not 
or  dared  not  compass  by  his  own  efforts:  and  it  is  difficult  to  avoid 
the  conclusion  that  the  stiffness  is,  in  the  main,  an  instinctive  act  to 
prevent  the  movement  which  gives  rise  to  the  pain,  rather  than  spasm 
like  that  which  is  met  with  in  tetanus.  The  arms  are  affected  as  well 
as  the  legs,  but  not  to  the  same  degree.  They  are  weak — so  weak  that 
it  is  not  easy  to  find  strength  to  carry  the  food  to  the  mouth,  the  left 
arm  being  somewhat  the  weaker  of  the  two.  The  left  arm  also  cannot 
be  moved,  either  actively  or  passively,  without  giving  rise  to  pain  and 
rigidity,  to  pain  shooting  up  between  the  shoulders,  to  rigidity  flexing 
the  limb  somewhat  at  the  elbow,  arid  bending  the  thumb  slightly  into 
the  palm:  not  so  the  right  arm.  There  is  no  numbness  in  either  arm, 
and  no  very  decided  over-sensitiveness.  Mastication  is  difficult,  and 
deglutition  still  more  so,  apparently  from  the  muscles  set  in  movement 
becoming  stiff  in  moving.  The  breathing  is  shallow  and  slow;  the 
pulse  quick  (130)  and  very  wanting  in  strength;  the  skin  profusely 
perspiring  after  a  paroxysm,  and  hot  and  moist  at  other  times.  Thirst 
is  much  complained  of.  The  bladder  is  full,  and  it  cannot  now  be 
emptied  voluntarily.  The  urine  is  acid.  The  penis  is  flaccid,  and  has 
been  so  ever  since  the  commencement  of  the  illness.  The  bowels  have 
not  acted.  The  pupils  are  equal  and  natural,  and  there  is  no  headache 
or  other  "head  symptom." 

3(M. — A  tolerably  good  night  has  been  passed,  and  this  after-* 
noon  the  patient  thinks  himself  a  little  better. 

Slst. — There  has  been  a  bad  night,  and  much  ground  has  evi- 
dently been  lost  since  the  last  visit.  In  a  paroxysm  which  is  just 
over,  want  of  breath  was  experienced  rather  than  pain.  Sensation  is 
still  somewhat  exaggerated  everywhere.  Urine  cannot  be  passed 
without  the  catheter,  but  the  bowels  have  responded  to-day  to  a  dose 


MENINGITIS.  17 

of  castor  oil  and  spirits  of  turpentine  which  was  administered  yester- 
day. During  rny  visit  I  had  an  opportunity  of  seeing  the  patient  after 
a  paroxysm  as  well  as  in  it,  and  I  quite  satisfied  myself  that  the  mus- 
cular stiffness  of  the  paroxysm  soon  passed  off,  and  that  in  the  inter- 
val between  the  paroxysms  the  muscles  were  relaxed,  except  perhaps 
at  the  back  of  the  neck — with  this  possible  exception,  because  all 
along  the  head  remained  drawn  back  to  some  degree  upon  the  pillow. 

Jan.  1,  1865. — The  night  has  been  perfectly  sleepless,  with  now  and 
then  some  trifling;  lightheadedness.  The  paroxysms  of  pain,  stiffness, 
and  difficulty  of  breathing  are  not  so  frequent  (three  hours  have  passed 
since  the  last),  but  the  respiration  is  certainly  shallower  and  less  suffi- 
cient, and  the  pulse  more  rapid  and  unsteady.  There  is  the  same  want 
of  power  over  the  bladder.  When  I  left  the  ward  it  was  plain  enough 
that  the  patient  was  sinking ;  when  I  returned  two  hours  later  all  was 
over,  death  having  happened  in  a  fit  of  choking  and  suffocation  caused 
by  attempting  to  swallow  a  spoonful  of  beef-tea  with  a  morsel  of  bread 
sopped  in  it.  Tn  the  agony,  the  patient  not  only  sat  up  in  bed,  but  got  out 
of  bed  and  stood  for  a  moment  with  his  hands  bearing  upon  the  shoulders 
of  the  nurse  ivho  had  been  feeding  him.  The  body  was  examined  after 
death  by  my  friend  and  colleague,  Dr.  Bazire,  and  the  following  notes 
were  taken  at  the  time  from  his  dictation  : — 

"  Time,  twenty-four  hours  after  death.  Weather  frosty.  Cadaveric 
rigidity  well  marked.  The  muscles  of  the  back  dark  and  highly  con- 
gested. On  cutting  through  the  posterior  arches  of  the  vertebrae  the 
vertebral  vessels  are  seen  to  be  gorged  with  dark  fluid  blood.  There 
is  no  effusion  of  blood  outside  the  meninges  in  the  interior  of  the 
canal.  The  meninges  are  highly  congested  throughout  the  whole 
length  of  the  canal,  but  to  a  considerably  greater  degree  in  the  region 
between  the  scapula.  In  this  latter  region,  in  addition  to  the  thicken- 
ing, opacity,  and  intense  red  colour  of  the  dura  mater  elsewhere,  there 
are  streaks  in  its  substance  of  black  coagulated  blood.  The  arachnoid 
is  intensely  red,  and  the  pia  rnater  extremely  congested  in  the  same 
region.  Beyond  it,  the  dark  red  colour  of  the  dura  mater  gradually 
passes  into  a  lighter  shade,  and  becomes  a  bright  pink  near  the  cauda 
equina  in  one  direction,  and  near  the  medulla  oblongata  in  the  other. 
The  arachnoid  is  whitish  again  near  the  cauda  equina.  There,  is  no 
effusion  of  serosity,  blood,  or  pus,  either  between  the'meninges  or  on 
the  surface  of  the  cord  ;  indeed,  there  seems  to  be  a  smaller  quantity 
than  usual  of  cerebro-spinal  fluid.  The  substance  of  the  cord  itself 
looks  normal  in  consistence,  colour,  and  size.  The  central  vessel  of 
the  cord  is  highly  congested,  and  on  section  of  the  cord  there  exudes 
from  the  centre  fluid  black  blood  in  minute  drops.  The  cerebral 
meninges  are  normal.  The  cerebral  sinuses  are  highly  congested,  and 
the  same  appearances  of  congestion  (due  probably  to  the  mode  of 
death)  are  met  with  in  the  substance  of  the  brain.  The  organ  itself 
is  normal." 

The  symptoms  of  acute  spinal  meningitis  are  plainly  exhibited  in 
this  case,  and  there  need  be  no  difficulty  in  distinguishing  those  which 
are  of  primary  importance  from  those  which  are  secondary. 

As  symptoms  of  primary  importance  mav   be  enumerated  these: 
2 


18  DISEASES    OF   THE    SPINAL    CORD. 

fits  of  pain  along  the  spine  and  in  the  extremities  produced  by  move- 
ment ;  fits  of  muscular  stiffness  in  the  painful  parts  along  with  the 
pain ;  intervals  of  comparative  or  complete  freedom  from  pain  and 
muscular  stiffness  so  long  as  movement  can  be  avoided ;  absence  of 
paralysis;  some  exaltation  of  sensibility ;  loss  of  power  over  the 
bladder ;  partial  loss  of  power  over  the  bowel ;  absence  of  spinal  ten- 
derness. 

Fits  of  pain  along  the  spine  and  in  the  extremities  produced  by  move- 
ment.— This  pain,  as  I  think,  must  be  regarded  as  the  most  prominent 
symptom  in  acute  spinal  meningitis.  It  may  be  confined  to  the  region 
of  the  spine,  but  more  generally  it  shoots  into  the  extremities,  into  the 
legs  especially.  As  a  rule,  it  does  not  shoot  beltwise  round  the  trunk. 
It  is  brought  on  by  any  movement  of  the  trunk,  and,  in  great  measure 
at  least,  it  may  be  prevented  by  avoiding  such  movement.  It  is  often 
brought  on  also  by  moving  one  of  the  extremities,  the  pain  in  this 
case  beginning  in  the  limb,  and  extending  thence  to  the  spine.  It 
seems  to  depend,  in  part  at  least,  upon  the  same  cause  as  the  pain  of 
pleurisy,  viz.,  the  dragging  of  an  inflamed  and  therefore  exquisitely 
tender  serous  membrane,  and  its  character  is  certainly  more  like  the 
pain  of  pleurisy  than  of  rheumatism  (to  which  it  has  been  likened),  for 
it  occurs  in  the  same  sharp,  sudden,  breath-stopping  catches. 

Fits  of  muscular  stiffness  in  the  painful  parts  along  with  the  pain. — It 
is  usual  to  regard  this  stiffness  as  analogous  to  the  spasm  of  tetanus: 
it  is  necessary,  as  I  believe,  to  look  upon  it  as  expressing  an  instinc- 
tive act  of  muscular  contraction,  of  which  the  object  is  to  prevent  pain 
by  arresting  certain  movements  which  produce  pain.  The  spine  and 
extremities  cannot  be  moved  without  causing  pain:  the  stiffness  pre- 
vents the  pain  by  preventing  the  movement;  this  would  appear  to  be 
the  true  view.  This  explanation,  originally  given  by  M.  Dance  as 
applying  to  the  muscular  stiffness  in  a  case  of  acute  spinal  meningitis 
observed  by  him  and  recorded  by  M.  Ollivier,  applies  perfectly  to  the 
muscular  stiffness  of  the  case  which  has  been  related  as  the  text,  and 
it  applies,  as  I  believe,  with  the  same  exactness  to  all  cases  of  the 
kind.  Indeed,  I  believe  there  can  be  no  greater  mistake  than  to  con- 
found the  stiffness  in  question  with  the  spasm  of  tetanus.  This  will 
be  seen  more  particularly  when  speaking  of  tetanus:  and  here  I  will 
only  say  that  tetanus  in  its  most  violent  form  is  constantly  present 
where  there  are  no  signs  of  spinal  meningitis,  and  that,  in  the  few 
cases  in  which  such  signs  chance  to  be  met  with,  it  may  be  supposed 
that  the  inflammation  is  a  consequence  rather  than  a  cause  of  the  irri- 
tation which  gives  rise  to  the  tetanic  spasm — a  consequence  of  the 
irritation  in  the  vaso-motor  nerves  having  proceeded  until  it  has 
issued  in  paralysis  of  the  vaso-motor  nerves.  Nay,  after  what  has 
been  said  in  the  preliminary  remarks,  it  is  not  impossible  that  the 
spinal  meningitis  which  is  occasionally  associated  with  tetanus  may 
have  served  to  counteract  the  spasm  rather  than  to  cause  it.  At  any 
rate,  it  is  certain  that  spasm  of  the  spinal  muscles  is  not  so  marked  a 
phenomenon  in  acute  spinal  meningitis  as  in  tetanus,  and  that  it  is  not 
to  be  regarded  "comme  indiquant  positivement  la  phlegmasie  des 
membranes  de  la  moelle ;"  and  it  is,  to  say  the  least,  highly  probable 


MENINGITIS.  1, 

that  the  muscular  stiffness  which  simulates  true  tetanic  spasm  is  in 
great  measure  an  instinctive  act  of  muscular  contraction  to  prevent  a 
movement  which  produces  pain. 

Intervals  of  complete  or  comparative  freedom  from  pain  and  muscular 
stiffness  so  long  as  movement  can  be  avoided. — These  intervals  are  some- 
times of  considerable  length,  even  for  days.  According  to  my  own 
experience,  indeed,  the  rule  would  seem  to  be  that  as  long  as  the  pa- 
tient can  keep  still,  so  long  is  he,  comparatively  at  least,  free  from 
pain  and  stiffness — a  rule  which  is  very  different  from  that  which  ob- 
tains in  tetanus. 

Absence  of  paralysis. — The  patient  is  weak,  very  weak,  and  he  seems 
to  be  paralyzed,  but  in  reality  he  fears  to  move  because  movement 
brings  back  the  pain.  "  Les  mouvements,  qui  sont  en  quelque  sorte 
enchaine's  par  la  douleur,  ont  moins  de  force,  mais  ils  ne  sont  point 
paralyses."  (Ollivier,  p.  595.)  Let  this  fear  be  forgotten,  and  it  is 
possible  not  only  to  sit  up,  but  to  get  out  of  bed  and  stand,  as  hap- 
pened in  the  final  agony  of  the  patient  whose  case  I  have  given.  This 
power  of  movement  has  been  noticed  in  several  cases,  of  which  one  is 
related  by  Ollivier,  and  another  referred  to;  and  I  believe  it  would 
be  witnessed  in  all  cases  of  uncomplicated  acute  spinal  meningitis  in 
which  the  fear  of  suffering  pain  from  movement  was  not  the  one  ab- 
sorbing feeling. 

O  O 

Some  exaltation  of  sensibility. — In  the  case  which  I  have  given  there 
was  some  exaltation  of  sensibility  as  to  touch,  pain,  and  differences  of 
temperature,  but  to  no  very  marked  degree;  and  this  would  appear  to 
be  the  rule  in  cases  of  the  kind.  It  would  seem,  indeed,  that  numb- 
ness is  a  purely  accidental  symptom,  which  is  never  present  unless 
the  substance  of  the  cord  iu  implicated  in  the  rneningeal  inflammation. 

Loss  of  power  over  the  bladder. — In  acute  spinal  meningitis,  when  the 
symptoms  are  fully  developed,  this  particular  symptom  is  scarcely 
ever  absent,  if  ever.  Before  this  time  it  may  be  absent,  as  it  was  in 
the  case  on  which  I  am  commenting;  but  this  absence  must  certainly 
be  looked  upon  as  the  exception  rather  than  the  rule.  Not  unfre- 
quently  the  inability  to  empty  the  bladder  is  preceded  by  a  state  of 
irritability  which  makes  it  necessary  to  pass  water  almost  incessantly. 

Partial  loss  of  power  over  the  bowel. — On  this  point  M.  Ollivier  makes 
a  remark  which  is  certainly  true:  "  Je  ferai  remarquer  que  1'abolition 
des  fonctions  de  la  vessie  persiste  toujours  au  rneme  degre"  depuis  le 
commencement  jusqu'a  la  fin,  tandis  qu'il  n'en  est  pas  de  merne  pour 
1'intestin,  puisqu'il  y  a  assez  souverit  des  garderobes  naturelles  dans 
les  derniers  temps  de  la  maladie."  (Vol.  ii.  p.  601.) 

Absence  of  spinal  tenderness. — This  absence  is  certainly  a  common, 
if  not  a  constant,  feature  of  acute  spinal  meningitis.  In  some  chronic 
cases,  no  doubt,  there  may  be  some  local  spinal  tenderness,  but  on 
inquiry  these  prove  to  be  cases  in  which  the  phenomena  of  spinal  irri- 
tation are  mixed  up  with  those  of  spinal  inflammation — in  which  the 
inflammatory  affection  is  complicated  with  that  condition  of  which, 
as  will  appear  in  due  time,  local  spinal  tenderness  is  the  distinctive 
feature. 

These  are  the  points  which  may  be  regarded  as  of  primary  import- 


20  DISEASES    OF    THE    SPINAL    CORD. 

ance  in  comparison  with  those  which  have  still  to  be  considered, 
namely — absence  of  marked  spasmodic  symptoms,  difficulty  of  masti- 
cation and  deglutition,  difficulty  of  breathing,  no  increased  reflex  ex- 
citability, no  priapism,  fits  of  perspiration  no  active  inflammatory 
fever,  no  marked  "  head-symptoms." 

Absence  of  marked  spasmodic  symptoms. — The  rigidity  which  attends 
upon  the  paroxysms  of  pain  has  been  seen  to  be  in  the  main  an  in- 
stinctive act  of  muscular  contraction  to  prevent  a  movement  which 
produces  pain,  and  there  appear  to  be  no  other  symptoms  of  a  spas- 
modic character  which  occupy  a  conspicuous  place  in  the  history  of 
spinal  meningitis.  Or  if  there  be  any  such  symptoms,  these  are  in  all 
probability  confined,  as  were  the  jerks  and  starts  in  the  case  under 
consideration,  to  that  early  period  of  the  disorder  in  which  it  may  be 
supposed  that  actual  meningeal  inflammation  was  not  developed — to 
the  so  called  cold  stage  of  the  disorder  probably. 

Difficulty  of  mastication  and  deglutition. — This  difficulty  is  often  ab- 
sent, and  when  present  it  is  at  most  a  trifling  trouble  comparatively. 
There  is  no  true  trismus  as  in  tetanus;  there  is  at  most  only  stiffness 
which  prevents  the  jaws  from  opening  easily  and  moving  freely.  This 
stiffness,  moreover,  is  late  in  making  its  appearance,  whereas  in  tetanus 
trismus  is  one  of  the  very  first  symptoms.  In  a  word,  difficulty  of 
mastication  and  swallowing  would  seem  to  occur  only  in  those  cases 
of  spinal  meningitis  in  which  the  higher  portions  of  the  cord  are  im- 
plicated. 

Difficulty  of  breathing. — This  difficulty  is  always  present  in  some  de- 
gree, and  especially  during  a  paroxysm  of  pain  and  stiffness.  In  some 
cases,  indeed,  the  movement  of  the  chest  may  be  actually  suspended 
at  this  latter  time,  and  death  may  happen  from  this  cause,  as  indeed 
was  the  case  in  a  patient  whom  I  saw  not  long  ago  with  Dr.  Julius,  of 
Richmond. 

No  increased  reflex  excitability. — This  is  not,  perhaps,  what  might  be 
expected  theoretically:  but,  be  the  explanation  what  it  may,  the  fact 
would  seem  to  be  that  reflex  irritability  is  not  increased  in  acute  spinal 
meningitis  in  the  way  in  which  it  is  ordinarily  increased  in  tetanus. 
So  far  as  I  have  been  able  to  ascertain  there  would  seem  to  be  no 
material  change  in  reflex  excitability  in  the  meningeal  inflammation. 

No  priapism. — The  cases  in  which  erection  of  the  penis  would  seem 
to  be  a  symptom  appear  to  be  those  in  which  the  substance  of  the 
cord  is  affected  rather  than  the  membrane — cases  too  in  which  the 
seat  of  the  disease  is  in  the  cervical  and  upper  dorsal  region  rather 
than  in  the  lumbar  region.  At  any  rate,  it  would  seem  to  be  the 
rule  for  the  penis  to  be  flaccid  in  uncomplicated  cases  of  acute  spinal 
meningitis. 

fits  of  perspiration. — As  in  tetanus  these  follow  a  paroxysm  almost 
invariably,  especially  in  the  latter  stages  of  its  disease.  Of  this  there 
appears  to  be  sufficient  evidence. 

No  active  inflammatory  fever. — Thirst  is  a  frequent  symptom  through- 
out, and  there  may  be  at  first  some  heat  of  skin,  but  in  the  most  acute 
cases  there  is  little  or  no  active  sympathetic  fever.  On  the  contrary, 
there  is  usually,  even  in  the  cases  which  have  most  claim  to  be  con- 


MENINGITIS.  21 

sidered  as  acute,  a  decided  want  of  febrile  reaction  from  the  beginning 
to  the  end. 

No  marked  head-symptoms. — In  very  many  cases  inflammation  of 
the  spinal  meninges  is  only  a  part  of  a  more  general  disorder  in  which 
the  cerebral  meninges  are  also  implicated,  and,  therefore,  "  head-symp- 
toms," of  one  kind  or  other  will  often  enough  be  mixed  up  with  the 
spinal  symptoms ;  but  in  cases  like  the  one  under  consideration,  where 
the  spinal  meninges  were  alone  inflamed,  "  head-symptoms"  do  not 
figure  at  all,  or  figure  only  as  phenomena  of  very  secondary  import- 
ance. Upon  this  point  there  is  no  lack  of  evidence.  Where  spinal 
meningitis  is  chronic  in  its  course  its  symptoms  are  often  so  mixed  up 
with  the  protean  symptoms  of  spinal  irritation  (of  which  more  in  due 
time)  as  only  to  be  detected  with  great  difficulty.  It  may  be  sus- 
pected that  the  meninges  are  affected  by  inflammation  rather  than  by 
simple  irritation  if  fits  of  pain  and  stiffness  are  produced  by  movement 
in  the  spine  and  extremities,  and  if  there  be  at  the  same  time  no 
spinal  tenderness,  no  paralysis,  and  no  tingling  or  numbness  ;  and  this 
is  all  that  can  be  said  except  this,  that  this  suspicion  will  gather 
strength  if  there  be  chronic  disease  in  the  bones  and  ligaments  of  the 
spine.  But  it  may  be  questioned  whether  long-continued  contraction 
of  the  muscles  of  one  or  more  of  the  extremities  or  of  the  cervical 
muscles  can  be  reckoned  among  these  symptoms,  for  such  contraction 
is  certainly  common  enough  in  cases  where  the  only  condition  of  dis- 
order in  the  spinal  cord  or  its  membrane  is  one  which,  from  the  sud- 
den way  in  which  it  begins  and  ends,  and  for  other  reasons  as  well, 
would  seem  to  be  one  of  simple  irritation. 

2.  POST-MORTEM  APPEARANCES. — As  Ollivier  pointed  out,  the  traces 
of  spinal  meningitis  after  death  are  met  with  usually,  not  in  the  arach- 
noid membrane,  which  is  non-vascular,  but  in  the  subjacent  vascular 
tissue.  The  arachnoid  is  so  thin  and  transparent  as  to  allow  the  vas- 
cular injection  produced  by  the  inflammation  in  the  deeper  structures 
to  appear  through  it,  and  that  is  all.  This  injection  is  generally  less 
evident  on  the  surface  of  the  cord  than  on  that  of  the  dura  mater, 
because  in  the  former  place  it  is  hidden  by  the  effusion  of  turbid, 
sero-purulent,  or  purulent  fluid  in  the  space  between  the  arachnoid 
and  pia  mater — in  the  space  naturally  occupied  by  the  rachidian  fluid 
— is  hidden  by  an  effusion  which,  before  the  arachnoid  is  opened,  often 
causes  the  cord  to  have  a  swollen,  opaque,  yellowish- white,  or  yellow- 
ish appearance.  Any  fluid  effusion  is  usually  in  this  space,  but  some- 
times there  may  be  fluid,  in  this  case  often  sanguinolent,  in  the  space 
outside  the  dura  mater,  especially  if  there  be  disease  in  the  bones  or 
ligaments  of  the  spine.  Sometimes  the  rachidian  space  is  obliterated 
here  and  there  by  inflammatory  adhesions  ;  sometimes  the  surface  of 
the  arachnoid  is  roughened  or  otherwise  altered  by  calcareous  or  other 
deposits  in  patches  :  sometimes  the  opposed  surfaces  of  the  arachnoid 
are  more  or  less  adherent;  but  generally  the  surfaces  of  the  arachnoid 
are  smooth  and  free,  and  the  inflammatory  products  are  met  with  below 
this  membrane,  and  not  above  it.  Very  often,  also,  the  proper  signs 
of  spinal  meningitis  are  mixed  up  with  those  of  cerebral  meningitis  or 


22  DISEASES    OF    THE    SPINAL    CORD. 

myelitis,  or  with  those  of  disease  in  the  bones  or  ligaments  of  the 
spine. 

3.  CAUSES. — The  causes  of  spinal  meningitis  are  often  very  obscure. 
In  some  cases  it  is  rheumatism,  or  syphilis,  or  the  suppression  of  some 
menstrual,  hsemorrhoidal,  or  other  habitual  discharge,  or  the  spreading 
of  cerebral  meningitis  downwards,  or   of  disease  in  the  bones  and 
ligaments  of  the  spine  inwards,  which  would  seem  to  figure  as  a  cause  ; 
in  other  cases  it  is  a  casual  injury  to  the  back,  or  a  chill  caught  by 
lying  on  the  back  on  the  cold  and  damp  ground,  or  some  particular 
disease,  as  tetanus,  chorea,  or  hydrophobia,  to  which  blame  appears 
to  belong.     In  fact,  the  causes  are  legion,  and  it  is  impossible  to  con- 
nect spinal  meningitis  with  any  particular  cause  or  set  of  causes. 

4.  DIAGNOSIS. — One  or  two  points  of  diagnosis  have  been  men- 
tioned incidentally  when  dealing  with  the  symptoms  of  spinal  menin- 
gitis, and  with  these  it  is  best  to  be  content  at  present,  for  before  this 
matter  can  be  gone  into  advantageously  materials  must  be  had  which 
can  only  be  forthcoming  when  the  phenomena  of  myelitis,  spinal  con- 
gestion, and  other  spinal  maladies  have  been  passed  in  review. 

5.  PROGNOSIS. — Acute  spinal  meningitis  is,  without  doubt,  a  very 
formidable  and   fatal  disease.     There  are,  indeed,  few  well-authenti- 
cated instances  of  recovery  on  record,   and  by  some  it  is  doubted 
whether  there  be  any.     Life  may  be  cut  short  in  four  or  five  days,  or 
it  may  be  prolonged  to  twenty  or  thirty  days,  but  not  often — not 
often,  indeed,  beyond  six  or  seven  days.     In  thesubacute  and  chronic 
forms  of  the  disease,  the  prognosis  is  of  course  less  gloomy,  but  even 
here  it  is  far  from  cheering. 

6.  TREATMENT. — In  all  cases  of  spinal  meningitis,  rest  in  the  recum- 
bent position,  more  or  less  strictly  enforced  according  to  the  urgency 
or  leniency  of  the  symptoms,  is  indispensable,  the  best  position,  per- 
haps, being  not  strictly  on  the  back,  but  rather  upon  the  side,  arid  with 
the  limbs  a  little  lower  than  the  back,  so  as  to  favour  the  draining 
away  of  blood  from  the  congested  parts,  and  at  the  same  time,  to 
facilitate  the  use  of  the  local  applications  to  the  spine  which  may  be 
necessary.     Upon  this  point  there  can  be  little  or  no  difference  of 
opinion  ;  upon  all  other  points,  in  all  probability,  few  will  think  alike. 
For  my  own  part,  I  should  be  disposed  to  place  most  confidence  in 
iodide  of  potassium  and  opium,  with  the  local  application  of  ice  to  the 
back  in  acute  cases,  and  to  bichloride  of  mercury,  with  counter-irrita- 
tion in  one  form  or  other  to  the  spine,  in  chronic  cases.     At  the  same 
time,  I  am  inclined  to  think  that  the  present  fashion  has  set  very 
unwarrantably  against  the  old  practice  of  giving  calomel  and  opium, 
so  as  to  affect  the  gums  slightly  and  speedily,  and  of  using  local,  if 
not  general,  bleeding  in  acute  inflammatory  disease.     There  can,  I 
think,  be  little  doubt  as  to  the  marked  influence  for  good  of  calomel 
and  opium  in  acute  inflammation  of  serous  membranes;  and  it  would 
require  very  little  persuasion  to  induce  me  to  prefer  this  mode  of 
treatment  to  that  by  iodide  of  potassium  in  acute  spinal  meningitis; 
and,  further,  I  can  readily  believe  that  in  such  a  case  recovery  would 


MYELITIS.  23 

be  promoted  by  a  judicious  abstraction  of  blood.  I  have  twice  seen 
symptoms,  so  closely  resembling  those  of  acute  spinal  meningitis  as 
not  to  be  distinguished  from  them,  disappear  coincidently  with  the 
occurrence  of  local  hemorrhage,  once  from  piles,  once  in  the  form  of 
menstruation  ;  and  I  can  well  believe  that  a  similar  result  might  be 
furthered  by  the  application  of  leeches  around  the  anus  or  to  the  cervix 
uteri — to  these  parts  rather  than  to  the  back,  because  their  vessels 
would  seem  to  communicate  more  directly  with  the  deep  spinal  ves- 
sels. It  is  very  probable,  however,  that  the  time  will  soon  pass  in 
which  depletion  in  any  form,  or  depressing  remedies  of  any  kind,  are 
required,  and  that  the  indications  will  rather  be  towards  brandy,  or 
ammonia,  or  ether,  than  towards  the  remedies  which  have  been  men- 
tioned, for  all  acute  diseases  of  the  spinal  cord  would  seem  to  have  a 
rapidly  devitalizing  influence  upon  the  system.  In  acute  cases  the 
catheter  may  be  necessary  to  empty  the  bladder ;  in  chronic  cases, 
aching  and  stiffness  of  the  limbs  may  point  to  friction  and  shampoo- 
ing as  likely  means  of  relief.  In  every  case  there  is  sure  to  be  some 
peculiarity  to  which  attention  must  be  directed  if  the  plan  of  treatment 
be  all  that  it  ought  to  be ;  and,  in  short,  every  case  must  be  treated  on 
its  own  merits. 

II.  MYELITIS. 

Myelitis,  or  inflammation  affecting  the  substance  without  involving 
the  membranes  of  the  cord,  is  a  well-defined  and  not  very  uncommon 
disease.  It  may  occur  in  an  acute  or  in  a  chronic  form:  it  may  be 
general  or  partial :  and,  to  say  the  least,  its  features  are  quite  as  well 
marked  and  distinctive  as  those  of  spinal  meningitis. 

1.  SYMPTOMS. — As  an  instance  of  acute  myelitis,  and  as  a  text  for 
what  has  to  be  said  under  this  head,  I  take  the  notes  of  the  case  of  a 
hospital  patient  under  my  care  not  long  ago. 

Case. — Charles  K.,  a  draper's  assistant,  twenty-six  years  of  age, 
unmarried,  a  patient  admitted  into  the  National  Hospital  for  the 
Paralyzed  and  Epileptic  on  the  9th  of  June,  1864. 

(a)  The  chief  symptoms  complained  of  are  paralysis  and  anaesthesia 
below  the  waist,  a  disagreeable  feeling  of  tightness  around  the  waist, 
inability  to  pass  water,  involuntary  stools,  and  pain  in  the  left  side  of 
the  chest.  Above  the  waist,  the  power  of  movement  and  the  power  of 
sensation  are  natural ;  below  the  waist,  all  the  voluntary  muscles  are 
entirely  paralyzed,  and  the  sensibility  to  pain,  to  tickling,  to  differ- 
ences of  temperature,  as  well  as  to  touch,  are  completely  lost.  Pres- 
sure along  the  spine  is  felt  above  the  point  to  which  the  anaesthesia 
reaches,  but  not  below  it,  and  where  felt  the  patient  bears  it  without 
wincing.  In  other  words,  there  is  no  tenderness  on  pressure  in  that 
part  of  the  spine  which  preserves  its  sensibility.  The  feeling  of 
warmth  produced  by  passing  a  sponge  soaked  in  moderately  hot  water 
along  the  spine  is  felt  above  the  point  to  which  the  anaesthesia  reaches, 
but  not  below  it,  and,  where  felt,  the  feeling  of  heat  is  natural,  except 
at  the  line  of  junction  between  the  sensitive  and  insensitive  parts,  and 
there  the  feeling  produced  is  that  of  burning.  Moreover,  the  warm 


24  DISEASES    OF    THE    SPINAL    CORD. 

sponge  produces  the  same  feeling  of  burning  all  around  the  body  in 
the  course  of  this  line  of  junction,  and  thus  it  is  plain  that  this  local 
over-sensitiveness  to  heat  is  not  confined  to  the  spine.  No  reflex  move- 
ments are  produced  by  tickling  the  soles  of  the  feet.  The  alse  nasi 
work  very  much,  the  lips  are  somewhat  dusky,  the  lower  intercostal 
muscles  are  motionless  and  the  accessory  inspiratory  muscles  are  in 
full  work,  the  air  passages  (especially  on  the  left  side)  are  loaded  with 
phlegm,  the  pulse  is  hurried  and  weak,  the  skin  is  moist  and  some- 
what  cooler  than  natural,  and  the  voice  is  so  low  as  to  be  scarcely 
audible.  A  cough  of  the  feeblest  sort  is  almost  incessant,  but  the  ex- 
piratory power  at  command  is  altogether  insufficient  to  bring  about 
the  expectoration  which  is  so  much  wanted.  All  appetite  is  gone, 
but  food  can  be  taken,  and  there  is  no  thirst,  or  none  to  speak  of. 
The  urine,  which  is  acid,  and  of  the  specific  gravity  of  1015,  has  to 
be  drawn  off  by  the  catheter.  There  is  no  priapism.  A  stool  has  just 
passed  without  the  patient  being  aware  of  it  until  his  nose  took  account 
of  the  accident. 

(b)  A  week  ago,  on  awaking  from  a  short  nap,  the  patient  found 
that  his  toes  had  gone  to  sleep,  and  that  he  had  to  "  take  long  breaths." 
Instead  of  passing  off',  the  feeling  of  tingling  spread  from  the  toes  to 
the  feet,  from  the  feet  to  the  legs,  from  the  legs  to  the  thighs,  until  it 
reached  the  seat,  becoming  less  and  less  endurable  as  it  spread,  and 
being  at  last  accompanied  by  a  feeling  of  tightness  around  the  waist 
and  around  the  left  instep,  and  by  a  state  of  restlessness  which  made 
it  impossible  to  sit  still  for  more  than  a  moment  at  a  time.  After 
suffering  in  this  way  for  a  couple  of  hours,  an  attempt  to  pass  water, 
.which  failed  altogether,  was  followed  by  an  almost  intolerable  uneasi- 
ness at  the  end  of  the  penis,  and  by  a  sudden  weakness  in  the  legs 
which  make  it  necessary  to  remain  on  the  bed  upon  which  he  had 
fallen.  Up  to  this  time  there  had  been  no  difficulty  in  standing  or 
walking,  not  even  in  going  up  and  down  stairs.  A  friend  of  the  pa- 
tient's now  present  says:  "I  saw  him  on  the  evening  of  the  day  on 
which  he  was  attacked,  a  couple  of  hours  or  so  after  he  had  been 
obliged  to  take  to  his  bed.  I  thought  he  was  suffering  from  severe 
rheumatic  pains.  For  some  hours  those  pains  were  excruciating.  I 
had  never  before  seen  any  one  suffer  so  much.  He  tossed  about  in 
dreadful  agony  :  he  roared  out  with  pain  often,  and  when  not  roaring, 
he  groaned."  Having  thus  passed  seven  or  eight  miserable  hours,  he 
fell  asleep  and  slept  until  breakfast  time  next  day.  Upon  waking  in 
the  morning  he  could  neither  move  his  legs  nor  empty  his  bladder; 
he  had  lost  all  feeling  below  the  waist,  and  all  the  miserable  feelings 
which  had  kept  him  in  a  state  of  continual  unrest  before  he  fell  asleep 
were  gone.  On  inquiring  whether  these  feelings  were  of  the  character 
of  pain,  he  says,  "No,  not  exactly,  worse  than  pain,  one  continued 
numb  stinging  feeling,  as  if  the  parts  were  asleep,"  so  that  the  friend's 
words  which  have  just  been  quoted  must  be  taken  as  meaning  not 
exactly  what  they  seem  to  mean  in  this  particular.  For  the  six  days 
preceding  his  admission  to  the  hospital  a  state  of  imperfect  priapism 
was  apt  to  come  on  of  itself,  or  to  be  brought  on  by  introducing  a 
catheter  to  draw  oft' the  water,  and  this  is  the  only  point  remaining  to 


MYELITIS.  25 

be  noticed  here,  for  in  other  respects  the  condition  seems  to  have  re- 
mained stationary,  except,  perhaps,  that  a  little  ground  was  lost  every 
day. 

The  patient  seems  to  have  come  of  a  healthy  family,  and,  though 
never  very  strong,  to  have  himself  always  enjoyed  tolerably  good 
health.  He  was  confined  to  the  house  tor  a  few  days  about  two 
months  ago  for  "  influenza,"  and  this  is  the  only  illness  of  any  kind  he 
remembers  to  have  had.  He  says,  "  I  was  fatigued  by  a  long  walk  on 
the  day  I  was  taken  ill,  and  for  a  month  and  more  I  had  felt  more 
tired  in  my  back  and  legs  than  usual  in  an  evening,  and  more  rheu- 
matic— less  up  to  the  mark  ;"  and  also,  "  My  back  always  ached  at  the 
end  of  the  day's  work,  and  so  did  my  legs,  and  I  was  always  glad  to 
go  to  bed  soon,  for  in  bed  I  was  comfortable:"  and  besides  these 
statements  there  appears  to  be  nothing  at  all  calculated  to  throw  light 
upon  the  history  of  his  present  malady. 

Jan.  10.  Early  this  morning,  after  a  sleepless  night,  a  severe  rigor 
commenced  in  the  right  arm,  and  then  extended  first  to  the  back,  and 
afterwards  to  the  whole  body.  This  rigor  continued  a  full  quarter  of 
an  hour,  and  was  followed  by  profuse  perspiration.  During  its  con- 
tinuance the  paralyzed  parts  were  very  cold:  after  it  had  ceased  the 
warmth  returned,  and  brought  with  it  a  considerable  mitigation  of  the 
cough  and  trouble  of  breathing.  Indeed,  after  the  establishment  of 
reaction,  difficulty  of  breathing  ceased  to  be  an  urgent  symptom,  except 
for  a  moment  or  two  after  waking  from  an  occasional  and  very  brief 
doze.  The  anassthesia  in  the  trunk  has  mounted  full  an  inch  higher 
since  yesterday,  but  it  has  not  extended  to  either  of  the  upper 
extremities.  Priapism  occurs  frequently.  The  pulse  is  150,  the 
respirations  are  86  in  the  minute. 

IWi.  There  has  been  no  sleep  in  the  night.  The  engorged  condi- 
tion of  the  lungs  has  gained  headway,  and  the  harassing  suffocative 
cough  has  returned.  Hiccough  is  frequent  and  distressing.  Once 
during  the  day  the  passage  of  the  catheter  was  obscurely  felt,  this 
being  the  first  sign  of  feeling  in  this  part  since  the  commencement  of 
the  illness.  The  urine  is  decidedly  acid.  The  electro-contractility 
and  electro-sensibility  of  the  paralyzed  muscles  is  annihilated. 

12/A.  For  the  last  twenty-four  hours  the  increased  difficulty  of 
breathing  attending  sleep  has  caused  the  patient  to  wake  immediately 
if  he  for  a  moment  forgot  himself.  "I  can't  breathe  except  I  keep 
awake,"  he  said  in  a  voice  scarcely  audible;  and  also,  "I  hope  I  have 
not  long  to  live."  The  passage  of  the  catheter  is  still  obscurely  felt, 
and  the  escape  of  flatus  and  feces  is  perhaps  not  so  entirely  unfelt  as 
it  has  been  since  the  commencement  of  the  illness.  In  other  parts  the 
anaesthesia,  like  the  paralysis,  remains  as  complete  as  ever.  The  urine 
is  still  acid,  distinctly  so.  For  the  last  twenty-four  hours  there  has 
been  no  priapism,  and  scarcely  any  cough.  At  present  hiccough  is 
almost  constant,  the  pulse  is  fluttering,  the  hands  are  cold  and  clammy, 
and,  in  short,  the  signs  of  the  near  approach  of  death  are  not  to  be 
mistaken. 

IBlh.  The  patient  lingered  through  the  night,  and  died  about  day- 
break; his  mind  unhappily  remaining  too  clear  to  the  very  last. 


26  DISEASES    OF   THE    SPINAL    CORD. 

The  notes  of  the  post-mortem  examination  are  as  follows: — 

14^,4.30  P.M.  Rigor  mortis  is  fully  established  everywhere.  The 
dependent  parts  present  considerable  signs  of  suggillation,  especially 
along  the  course  of  the  spine,  and  there  is  incipient  breaking  of  the 
skin  on  both  the  nates.  The  arachnoid  covering  of  the  cord  every* 
where  is  clear,  smooth,  and  without  any  traces  of  inflammation.  The 
outside  of  the  lumbar  enlargement  is  curiously  nodulated.  On  making 
a  longitudinal  section,  the  whole  substance  of  the  cord,  from  the 
brachial  enlargement  to  its  inferior  extremity,  is  found  to  be  of  a 
yellowish-red  colour,  softened  in  a  remarkable  manner,  and  in  the 
lumbar  region  alm6st  like  cream  in  consistence.  Several  small 
patches  of  extravasated  blood  are  scattered  in  the  softened  structure, 
these  patches  being  undefined  in  outline,  more  numerous  in  the  lum- 
bar than  in  the  dorsal  region  of  the  cord,  and  situated  chiefly  in  the 
posterior  columns.  The  red  discoloration  which  has  been  mentioned 
is  most  marked  in  the  neighbourhood  of  these  patches.  The  examina- 
tion did  not  extend  further,  the  friends  of  the  patient  consenting  to  it 
only  on  condition  that  it  should  be  thus  partial. 

15th.  On  examining  some  portions  of  the  diseased  cord  under  the 
microscope,  the  natural  structure  is  found  to  be  altogether  broken 
down,  and  mixed  up  with  blood  corpuscles,  exudation  granules,  and 
(in  fewer  numbers)  pus-corpuscles. 

With  a  view  to  arrive  at  a  knowledge  of  the  general  features  of 
myelitis,  I  select  as  the  principal  points  for  comment  in  this  particular 
case  the  following:  Paraplegic  anesthesia,  ushered  in  by  tingling  or 
some  similar  sensation  in  the  parts  which  eventually  became  anes- 
thetic; paraplegic  paralysis,  ushered  in  by  uncontrollable  restlessness  ; 
a  disagreeable  feeling  of  tightness  around  the  waist  and  elsewhere ; 
absence  of  pain  in  the  spine  or  extremities — of  pain  produced  by 
movement  especially ;  absence  of  trismus  and  other  spasmodic  or 
convulsive  symptoms ;  retention  of  urine ;  involuntary  stools ;  absence 
of  pain  on  pressure  (spinal  tenderness)  in  any  part  of  the  spine; 
increased  sensibility  to  differences  of  temperature,  by  which  mode- 
rately warm  or  iced  water  gave  rise  to  a  feeling  of  burning  instead  of 
the  natural  feeling  over  the  vertebra  which  marks  the. upper  limit  of 
the  myelitis;  annihilation  of  reflex  excitability  in  the  paraplegic  parts  ; 
priapism;  acidity  of  urine;  comparative  voicelessness ;  impeded 
respiration ;  engorgement  of  lungs  and  other  viscera ;  tendency  to 
bed-sores;  loss  of  electro-contractility  and  electro  sensibility  in  the 
paralyzed  muscles;  absence  of  "head-symptoms;"  absence  of  fever. 

Paraplegic  anaesthesia,  ushered  in  by  tingling  or  some  similar  sensation 
in  the  parts  which  eventually  became  ancesthetic. — In  this  case  the  anaes- 
thesia was  developed  suddenly  during  the  first  night's  sleep;  it  was 
deep-seated  as"  well  as  superficial;  it  implicated  the  sensibility  to  pain, 
tickling,  and  differences  of  temperature,  as  well  as  that  of  touch;  it 
had  a  paraplegic  distribution ;  and  this  would  seem  to  be  the  rule  in 
cases  of  acute  myelitis.  In  chronic  cases  it  is  developed  more  gradu- 
ally, and  it  may  not  extend  to  all  the  various  forms  of  sensibility ; 
moreover,  it  may  in  some  instances  be  quasi  hemiplegic  instead  of 
paraplegic;  but  the  rule  in  acute  cases  appears  to  be  what  it  is  found 


MYELITIS.  27 

to  be  in  this.  The  anaesthesia  seems  to  be  usually  ushered  in  by 
tingling  or  by  some  analogous  sensation,  disagreeable  enough,  but 
not  amounting  to  actual  pain.  In  this  particular  case  the  pre- 
liminary sensation  was  not  pain,  but  an  unbearable  "numb  stinging" 
as  if  the  parts  were  asleep,  with  a  feeling  of  tightness  around  the 
waist,  and  around  one  of  the  insteps.  In  acute  cases  it  is  right  to 
speak  of  anesthesia  as  ushered  in  by  tingling  or  some  similar  sensation, 
but  scarcely  so  in  chronic  cases.  In  chronic  cases,  indeed,  these 
anomalous  sensations  may  never  exactly  come  to  an  end,  because  in 
these  cases  the  destruction  of  sensibility  may  never  get  beyond  numb- 
ness— may  never  reach  nearer  to  anaesthesia,  that  is  to  say,  than 
dysaesthesia. 

Paraplegic  paralysis,  ushered  in  by  uncontrollable  restlessness. — The 
paralysis  was  thus  ushered  in  in  the  case  under  consideration,  and  in 
two  similar  cases  which  have  corne  specially  under  my  own  notice — by 
restlessness,  and  not  by  any  more  marked  tremulous,  convulsive,  or  spas- 
modic symptom.  Neither  does  it  appear  that  a  different  rule  obtains  in 
other  cases,  acute,  subacute,  or  chronic.  In  the  great  majority  of  cases, 
no  doubt,  the  paralysis  has  a  paraplegic  form,  but  in  a  few  cases  it  is  not 
so.  In  the  great  majority  of  cases,  the  paralysis  is  accompanied  by 
numbness,  but  not  absolutely  in  all.  Sometimes,  for  example,  as  in 
the  case  in  which  the  paralyzing  lesion  is  limited  to  a  portion  of  one 
lateral  half  of  the  spinal  cord — the  case  about  which  enough  was  said 
in  the  preliminary  remarks — there  is  paralysis  without  numbness  on 
one  side,  and  numbness  without  paralysis  on  the  other  side.  Several 
cases  of  this  kind  are  on  record,  and  the  number  of  them  which  I  have 
myself  met  with  is  sufficient  to  convince  me  that  they  are  scarcely  to 
to  be  looked  upon  as  out  of  order  and  exceptional.  Sometimes,  also, 
as  in  the  case  where  the  paralyzing  lesion  is  confined  to  a  portion  of 
one  of  the  anterior  columns,  the  paralysis  may  be  divorced  from 
numbness,  and  not  only  so,  but  it  may  be  herniplegic  in  its  distribu- 
tion ;  and  in  such  a  case  it  may,  in  fact,  be  no  easy  matter  to  say 
whether  it  is  dependent  upon  a  cerebral  or  upon  a  spinal  cause.  In 
some  cases,  also,  the  paralyzing  lesion  may  be  so  localized  as  to  affect 
only,  or  chiefly,  an  arm  on  one  side  and  a  leg  on  the  other  side. 
Usually,  however,  the  paralysis  is  distinguished  by  being  associated 
with  numbness,  and  by  being  paraplegic  in  its  distribution. 

A  disagreeable  feeling  of  tightness  around  the  waist  and  elsewhere. — A 
feeling  of  circular  constriction  around  the  trunk,  or  around  some  part 
of  an  extremity,  around  the  trunk  especially,  is  so  common  as  to 
deserve  to  be  considered  as  an  almost  constant  symptom  in  myelitis. 
I  do  not  recall  a  case,  acute  or  chronic,  in  which  it  was  entirely  absent 
at  all  times. 

Absence  of  pain  in  the  spine  and  extremities — of  pain,  produced  by 
movement  more  especially. — In  chronic  cases  of  myelitis,  Dr.  Brown- 
Se'quard  speaks  of  "a  constant  pain  in  the  part  of  the  spine  corre- 
sponding to  the  upper  limit  of  the  inflammation  of  the  cord"  as  a 
characteristic  symptom ;  but  I  question  very  much  whether  this  state- 
ment is  in  accordance  with  well-sifted  clinical  facts.  Pain,  either  in 
the  spine  or  elsewhere,  is  not  mentioned,  for  example,  in  the  nineteen 


28  DISEASES    OF   THE    SPINAL    CORD. 

cases,  acute  or  chronic,  given  by  Ollivier,  except  in  three,  and  of 
these  three  the  myelitis  was  complicated  with  meningitis  in  two  and 
in  the  one  remaining  the  symptoms  justify  the  presumption  (and  there 
was  no  post-mortem  examination  to  set  it  aside)  that  the  same 
complication  existed.  At  any  rate,  it  is  certain  that  there  is  not  in 
uncomplicated  myelitis  that  severe  pain  in  the  back  and  limbs  which 
is  brought  on  or  aggravated  by  movement  in  spinal  meningitis. 

Absence  of  spasmodic  symptoms. — Ollivier  speaks  of  continuous  contrac- 
tion of  the  limbs  as  being  met  with  "  assez  ordinairement,"  in  chronic 
myelitis ;  but  the  cases  cited  by  this  excellent  observer  do  not  sub- 
stantiate this  statement.  Thus,  out  of  nineteen  cases  of  myelitis, 
complicated  and  uncomplicated,  acute  and  chronic,  there  are  three 
only  in  which  these  contractions  were  present,  and  not  one  of  the 
three  can  be  cited  correctly  as  a  case  of  myelitis.  In  one  of  the  three 
(No.  87)  the  sensibility  was  intact,  and  the  disease  of  the  cord  confined 
almost  exclusively  to  the  anterior  column;  in  another  (No.  93)  there 
was  obtuse  sensibility,  and  the  disease  was  chiefly  in  the  gray  matter ; 
and  in  the  third  (No.  94)  sensibility  remained,  and  there  was  no  post- 
mortem examination  to  show  what  the  disease  in  the  cord  really  was. 
In  each  one  of  these  cases,  also,  there  were  "  head  symptoms"  which 
do  not  figure  in  uncomplicated  myelitis.  Again,  prolonged  contraction 
of  the  extremities  is  a  not  unfrequent  symptom  in  cases  in  which  there 
is  neither  myelitis  nor  spinal  meningitis — cases  which  properly  come 
under  the  head  of  "spinal  irritation,"  and  about  which  more  will 
have  to  be  said  in  another  section  of  this  article.  In  these  cases  the 
contraction,  instead  of  pointing  to  inflammation  of  the  cord  or  its 
membranes,  is  really  no  more  than  one  of  a  series  of  so-called  hysterical 
phenomena.  It  is  a  sign  of  functional  disorder  only,  and  that  it  is  so 
is  evident  (these  among  other  proofs)  in  the  sudden  and  complete  way 
in  which  it  passes  off,  as  well  as  in  the  fact  that  it  does  not  leave 
behind  it  any  permanent  organic  traces.  It  depends  as  it  would  seem, 
upon  a  state  of  irritation  in  some  part  of  that  track  in  which  irritation 
gives  rise  to  prolonged  spasm — a  state  issuing,  it  may  be,  now  and 
then  in  inflammation,  but  in  itself,  so  far  as  the  condition  of  the  blood- 
vessels is  concerned,  diametrically  opposed  to  inflammation.  Nay, 
even  in  those  exceptional  cases  of  myelitis  in  which  there  is  increased 
reflex  excitability  in  the  paralyzed  limbs,  it  is  difficult  to  connect 
these  spasmodic  symptoms  with  the  inflammation.  Dr.  Brown-Se'quard 
says  :  "  When  the  dorso-lumbar  enlargement  is  inflamed,  reflex  move- 
ments can  hardly  be  excited  in  the  lower  limbs,  and  frequently  it  is 
impossible  to  excite  any.  On  the  contrary,  energetic  reflex  move- 
ment can  always  be  excited  when  the  disease  is  in  the  middle  of  the 
dorsal  region,  or  higher  up."  And  again,  when  speaking  of  the  reflex 
convulsions  which  may  happen  in  the  cases  where  the  inflammation  is 
in  the  middle  of  the  dorsal  region  or  higher  up,  he  says,  "  Convulsions 
do  not  take  place  at  the  beginning  of  the  inflammation,  but  some  time 
after,  and  they  recur  by  fits  for  months  and  years  after."  And  this  is 
precisely  what  happens.  In  a  word,  the  truth  would  seem  to  be  that 
these  reflex  spasmodic  movements  must  be  referred,  not  to  inflamma- 
tion in  the  lumbar  enlargement  of  the  cord,  nor  yet  to  inflammation 


MYELITIS.  29 

higher  up  in  the  cord  ;  for  in  this  case,  to  repeat  what  has  just  been 
said,  "  the  convulsions  do  not  take  place  at  the  beginning  of  the  inflam- 
mation, but  some  time  after,  and  they  recur  by  fits  for  months  and 
years  after."  They  happen,  as  it  would  seem,  after  the  inflammatory 
disorganization  has  interrupted  the  continuity  of  the  cord,  and  pro- 
duced a  state  of  things  analogous  to  that  of  a  guinea-pig,  or  other 
animal,  whose  spinal  cord  has  been  cut  across  experimentally — a  state 
of  things  of  which  increased  reflex  excitability  in  the  paralyzed  parts 
is  one  of  the  consequences.  Nor  is  a  different  conclusion  to  be  drawn 
from  the  occasional  presence  in  the  paralyzed  muscles  of  a  state  which 
is  analogous  to  or  identical  with  the  "late  rigidity"  of  Todd.  This 
"  late  rigidity"  is  very  different  to  "  early  rigidity."  In  "  early 
rigidity"  the  electro-motility  of  the  muscles  is  increased,  and  the 
muscles  relax  during  sleep,  and  to  a  less  degree  under  the  influence 
of  warmth.  The  muscular  contraction  is  evidently  of  the  nature  of 
spasm.  In  "late  rigidity,"  on  the  contrary,  the  muscles  are  wasted, 
their  electi'o-motility  annihilated,  and  sleep  or  warmth  do  not  tell  in 
causing  relaxation.  This  form  of  muscular  contraction,  indeed,  if  not 
identical  with  rigor  mortis,  is,  as  it  would  seem,  more  akin  to  this 
state  than  to  spasm.  In  the  case  of  myelitis  which  serves  as  my  text, 
there  was  none  of  the  painful  muscular  rigidity  produced  by  move- 
ment which  is  so  prominent  a  symptom  in  spinal  meningitis.  There 
was,  indeed,  no  spasmodic  symptom  of  any  kind,  with  the  exception 
of  the  rigor  which  ushered  in  the  extension  of  the  disease  on  the  day 
after  the  admission  of  the  patient  to  the  hospital.  And  this  absence 
of  spasmodic  symptoms  would  seem  to  be  the  rule  in  all  cases  of 
myelitis,  acute  or  chronic.  In  children,  it  is  true,  myelitis  may  be 
ushered  in  by  convulsion — in  which  case  the  convulsion  manifestly 
represents  the  rigor  which  may  usher  in  myelitis  in  adults,  and  as 
manifestly  belongs  to  the  precursory  stage  of  irritation,  and  not  to  the 
state  of  actual  inflammation — but  even  in  children,  unless  there  be 
some  meningeal  complication  along  with  the  myelitis,  this  preliminary 
convulsion  would  seem  to  be  a  rare  phenomenon. 

Want  of  control  over  the  bladder. — This  appears  to  be  the  earliest  as 
well  as  the  most  constant  of  the  symptoms  of  myelitis.  It  usually  de- 
pends upon  paralysis  of  the  accelerator  urinae  and  compressor  urethrse, 
but  now  and  thenit  wouldseem  to  be  connected,  for  a  while  at  least,  with 
a  state  of  spasm  in  the  latter  of  these  muscles,  in  which  case  the  drib- 
bling away  of  the  water  or  the  introduction  of  a  catheter  will  some- 
times produce  marked  reflex  spasms  in  the  legs.  I  remember  one  case 
— a  case  in  which  the  myelitis  seemed  to  have  interrupted  the  con- 
tinuity of  the  cord  high  up  in  the  back — where  an  attempt  to  use  the 
catheter  often  gave  rise  to  strong  reflex  spasms  in  both  legs,  and  to  a 
state  of  spasm  in  the  urethra  strong  enough  to  prevent  the  passage  of 
the  instrument. 

Want  of  control  over  the  rectum. — In  myelitis  paralysis  of  the  sphinc- 
ter ani  is  usually  associated  with  paralysis  of  the  accelerator  urinas  and 
compressor  urethras.  Now  and  then  also,  the  sphincter  ani,  instead  of 
being  paralyzed,  may  be  in  a  state  of  reflex  spasm  :  thus,  in  the  case 
to  which  I  have  just  referred,  the  administration  of  an  enema  was 


30  DISEASES    OF    THE    SPINAL    CORD. 

sometimes  rendered  impossible  by  the  spasm  set  up  in  the  sphincter 
ani  and  in  the  femoral  muscles  by  .the  pipe. 

Absence  of  local  spinal  tenderness. — As  in  spinal  meningitis,  so  in 
myelitis,  absence  of  tenderness  on  pressure  in  any  part  of  the  spine 
would  seem  to  be  the  rule,  and  not  the  exception.  Ollivier,  speaking 
of  pain  in  the  back  in  myelitis,  says,  "  Elle  n'est  jamais  rendue  plus 
aigue  par  la  pression,"  and  rny  own  experience  in  the  matter  is,  with- 
out question,  to  the  same  effect. 

Altered  sensibility  to  heat  and  cold  by  which  a  feeling  of  burning  is  felt 
when  a  sponge  soaked  in  moderately  warm  water  or  a  piece  of  ice  is  applied 
to  the  spine  immediately  above  the  seat  of  inflammation. — Several  years 
ago  it  was  pointed  out  by  Mr.  Copeland  that,  when  a  sponge  soaked 
in  water  a  little  above  the  temperature  of  the  blood  was  passed  along 
the  spine  from  above  downwards,  it  gave  rise  to  the  natural  feeling  of 
heat  until  it  reached  theinflamed  part,  and  that  then  thisfeeling  changed 
to  that  of  burning;  and  more  recently  Dr.  Brown-Se'quard  has  shown 
that  a  similar  result  is  arrived  at  by  passing  a  piece  of  ice  down  the 
spine,  the  natural  feeling  of  cold  being  felt  until  the  inflamed  part  is 
reached,  and  then  an  unnatural  feeling  of  burning.  In  many  cases, 
no  doubt,  all  this  would  seem  to  be  quite  true,  but  not  in  all,  perhaps 
not  in  the  majority :  and  therefore  it  is  impossible  to  look  upon  the 
feeling  of  burning  thus  produced  as  more  than  an  occasional  occur- 
rence in  myelitis. 

Annihilation  of  reflex  excitability. — What  has  to  be  said  under  this 
head  has  been  anticipated  when  speaking  of  the  absence  of  spasmodic 
symptoms  in  myelitis.  It  has  indeed  been  seen  to  be  the  rule  for  all 
reflex  movements  to  be  annihilated  or  greatly  weakened  in  the  paralyzed 
parts,  and  that  the  apparent  exceptions  to  this  rule  are  to  be  ex- 
plained, not  by  referring  the  increased  reflex  movement  to  myelitis, 
but  by  supposing  the  inflammatory  disorganization  to  have  inter- 
rupted the  continuity  of  the  cord  and  produced  a  state  of  things  ana- 
logous to  that  of  a  guinea-pig  whose  cord  has  been  cut  across  for 
experimental  purposes. 

Diminution  of  electro-motility  and  electro- sensibility  in  the  paralyzed 
muscles. — Except  in  those  few,  very  few,  cases  in  which  the  reflex 
excitability  is  increased,  the  electro-motility  and  electro-sensibility  of 
the  paralyzed  muscles  are  invariably  diminished  in  myelitis.  Where 
the  reflex  excitability  is  increased  the  electro-motility  may  also  be 
increased,  and  so  also  may  the  electro-sensibility,  but  more  generally 
the  increase  in  the  former  property  is  without  a  corresponding  in- 
crease in  the  latter.  The  paralyzed  muscles  are  wasted  in  almost 
all  cases,  and  relaxed  also,  except  in  those  few  cases  in  which  the 
paralysis  has  lasted  for  a  very  long  time  and  become  associated  with 
that  state  of  "late  rigidity"  which,  sooner  or  later,  is  always  found  to 
seize  upon  paralyzed  muscles.  Marshall  Hall  noticed  the  impairment 
of  irritability  in  spinal  paralysis,  and  was  of  opinion  that  an  opposite 
state  of  things  existed  in  cerebral  paralysis.  As  was  pointed  out  by 
Todd,  however,  this  supposed  distinction  between  spinal  and  cerebral 
paralysis  does  not  hold  good,  the  simple  fact  being  that  in  the  great 
majority  of  cases  of  cerebral  paralysis  the  irritability  of  the  paralyzed 


MYELITIS.  31 

muscles,  instead  of  being  increased,  is  either  not  materially  altered  or 
else  more  or  less  diminished — most  generally  diminished  in  a  very 
marked  degree.  In  a  word,  the  investigations  of  this  very  accomplished 
physician  show  most  clearly  that  in  cerebral  paralysis  the  irritability 
of  the  paralyzed  muscles  is  only  increased  in  those  comparatively  few 
cases  in  which  the  paralysis  is  associated  with  "  early  rigidity." 

Priapism. — It  is  difficult  to  attach  any  diagnostic  value  to  this 
symptom.  As  in  acute  spinal  meningitis,  so  in  acute  myelitis,  it  is 
sometimes  present  and  sometimes  absent,  less  frequently  present  in 
the  latter  affection  perhaps  than  in  the  former. 

Frequent  alkalinity  of  the  urine. — Dr.  Brown-Se'quard  says:  "One 
of  the  most  decisive  symptoms  in  myelitis  is  alkalinity  of  the  urine. 
There  is  no  patient  attacked  with  myelitis  in  the  dorsal  region  of  the 
cord  whose  urine  is  not  frequently  alkaline.  At  times,  especially 
after  certain  kinds  of  food,  the  urine  is  acid,  but  the  alkalinity  soon 
returns."  And  no  doubt  the  urine  is  very  generally  alkaline  in  mye- 
litis, especially  in  those  cases  in  which  the  paralysis  of  the  bladder 
has  led  to  secondary  disease  of  this  organ  ;  at  the  same  time,  as  in  the 
case  under  consideration,  the  urine  is  too  often  acid  to  make  it  possi- 
ble to  insist  upon  alkalinity  of  the  urine  as  a  necessary  feature  in 
myelitis. 

Dyspnoea, — Difficulty  of  breathing  was  a  very  urgent  symptom  in 
the  case  which  serves  as  my  text,  and  so  it  must  be  in  every  case 
where  respiratory  muscles  are  so  gravely  implicated  in  the  paralysis, 
and  where  the  lungs  are  so  much  engorged.  Indeed,  the  usual  way 
in  which  myelitis  proves  fatal  is  by  compromising  the  sufficiency  of 
the  respiration.  Now  and  then,  especially  when  chronic  inflamma- 
tion affects  the  higher  regions  of  the  cord,  the  difficulty  of  breathing 
may  occur  in  paroxysms  not  unlike  those  of  asthma,  but  usually  the 
difficulty  shows  itself  rather  as  simple  shortness  of  breath — shows 
itself  in  a  way  which  supplies  another  proof  of  the  absence  of  the 
spasmodic  element  in  the  history  of  myelitis. 

Want  of  power  in  the  circulation. — There  is  little  or  no  sympathetic 
fever  in  the  most  acute  form  of  myelitis;  and  in  the  ordinary  chronic 
forms,  the  feeble  pulse,  the  cedematous  condition  of  the  paralyzed 
extremities,  the  disposition  to  passive  engorgement  in  the  lungs  and 
elsewhere,  and  other  symptoms  of  like  meaning,  show  very  plainly 
that  the  state  of  the  circulation  is  eminently  asthenic.  It  would  even 
seem  as  if  there  were  something  in  the  very  fact  of  myelitis  which 
has  a  positive  influence  in  subtracting  power  from  the  circulation — 
which  exercises  a  devitalizing  influence  upon  the  system  generally. 

A  tendency  to  bed-sores,  wasting,  and  other  signs  of  defective  nutrition  in 
the  paralyzed  parts. —  Sooner  or  later,  generally  at  a  very  early  date,  a 
marked  disposition  to  bed-sores  in  places  where  paralyzed  parts  are 
subjected  to  pressure  is  apt  to  show  itself  in  myelitis,  and  so  also  are 
other  signs  of  defective  nutrition  in  the  same  parts,  such  as  cedema, 
dry  ness  and  scurfiness  of  the  skin,  and  a  wasted  and  flabby  state  of 
the  muscles.  So  marked,  indeed,  is  this  impairment  of  nutritive 
power  in  these  paralyzed  parts,  that  it  is  only  by  very  great  care  that 
bed-sores  and  the  other  lesions  which  have  been  mentioned  can  be 
prevented. 


82  DISEASES    OF    THE    SPINAL    CORD. 

Absence  of  head  symptoms. — In  cases  where  acute  myelitis  attacks 
the  higher  portions  of  the  cord,  there  may  be,  and  there  in  all  proba- 
bility will  be,  various  "head  symptoms" — vertigo,  singing  in  the  ears, 
grinding  of  the  teeth,  delirium,  convulsion,  coma,  or  others — but  these 
cases,  to  say  the  least,  are  not  common.  Whether  acute  or  chronic, 
indeed,  myelitis  is  much  more  apt  to  attack  the  lower  portions  of  the 
cord  than  the  upper,  in  this  respect  differing  from  spinal  meningitis; 
and  when  it  attacks  the  upper  portions  of  the  cord,  and  its  symptoms 
present  cerebral  complications,  the  chances  are  that  the  case  is  not 
simple  myelitis,  but  myelitis  with  more  or  less  spinal  meningitis  in 
adcmton. 

When  the  cord  is  affected  generally,  the  symptoms  of  myelitis  will 
not  differ  greatly  from  those  which  are  present  in  the  case  which  has 
been  given;  when  the  inflammation  is  more  localized,  the  symptoms 
will  vary  accordingly.  If,  for  example,  the  inflammation  be  limited,  as 
it  usually  is,  to  the  lumbar  enlargement  of  the  cord,  the  level  of  the 
paralysis  and  anaesthesia  will  be  proportionably  low  down  ;  and  if  the 
extreme  end  of  the  cord  only  be  affected,  it  is  possible  that  the  legs 
may  escape  altogether,  and  the  bladder  and  anus  be  alone  at  fault. 
As  indeed  the  level  of  the  inflammation  in  the  cord  falls  or  rises, 
so  must  the  level  of  the  paralysis  and  anaesthesia  fall  or  rise  also. 
Exaggerated  reflex  movements  in  the  inferior  extremities  will  also  (in 
all  probability)  be  associated  with  the  paralysis  and  anesthesia,  if  the 
lower  parts  of  the  cord  be  sound  and  the  inflammation  confined  to  a 
portion  of  the  cord  higher  up.  Again,  the  symptoms  which  are  pre- 
sent when  the  inflammation  is  limited  to  a  part  only  of  the  thickness 
of  the  cord  will  be  different  in  many  respects  from  those  which  are 
met  with  when  the  whole  thickness  is  affected.  If,  for  example,  a 
portion  (the  upper  half-inch  of  their  course  excepted)  of  the  anterior 
columns  be  affected  solely,  there  would  be  paralysis  without  anaesthesia; 
or  if  the  posterior  columns  were  alone  affected,  there  might  be  in- 
co-ordination  of  movement  and  some  hyperesthesia  instead  of  paralysis 
and  anesthesia.  In  short,  the  variations  of  symptoms,  which  occur 
where  myelitis  is  restricted  to  particular  parts  of  the  cord,  can  only 
be  properly  intelligible  to  him  who  has  clear  notions  respecting  those 
physiological  matters  which  were  glanced  at  in  the  preliminary  re- 
marks— which  were  then  glanced  at  chiefly  in  order  to  avoid  perplex- 
ing physiological  digression  and  discussion  in  the  present  place  among 
others.  I  will,  therefore,  assume  that  what  was  said  in  the  preliminary 
glance  at  some  points  in  the  physiology  of  the  spinal  cord,  will  serve 
to  explain  sufficiently  the  variations  of  symptoms  which  may  be  ex- 
pected to  exist  when  the  integrity  of  particular  parts  of  the  spinal 
cord  is  destroyed  by  myelitis  or  in  any  other  way :  and,  for  the  rest, 
I  will  only  say  that  myelitis  may  be  chronic  and  subacute  as  well  as 
acute  in  its  course,  and  that  these  several  varieties  interblend  insensi- 
bly the  one  with  the  other. 

2.  POST-MORTEM  APPEARANCES. — Myelitis  may  result  either  in 
softening  or  in  hardening  of  the  spinal  cord.  Most  frequently  the 
cord  is  broken  down,  reduced  to  a  yellowish  or  reddish  cream-like 


MYELITIS.  33 

consistence;  the  colour,  derived  from  the  admixture  of  pus  or  blood- 
corpuscles,  being  more  yellow  or  more  red  according  as  the  one  or 
the  other  of  these  corpuscles  predominate.  This  softening  may  affect 
the  whole  thickness  of  the  cord,  or  certain  parts  more  than  others, 
the  gray  matter  especially  ;  it  may  extend  from  one  end  of  the  cord 
to  the  other,  or  it  may  be  confined  to  certain  regions,  in  which  latter 
case  the  part  most  likely  to  be  affected  is  the  lumbar  enlargement ; 
and  it  would  often  seem  to  have  its  starting-point  in  the  central  gray 
matter,  which  is  the  most  vascular  part  of  the  cord.  In  the  first  stage 
of  myelitis  this  central  gray  matter  has  a  rosy  or  vinous  tinge,  which 
is  not  natural  to  it;  it  is  plainly  more  vascular  than  it  ought  to  be; 
and,  in  short,  it  has  undergone  the  very  same  change  which  is  met 
with  in  the  gray  matter  of  the  brain  in  encephalitis.  Sometimes  the 
spinal  cord  is  considerably  swollen,  and  sometimes  the  surface  may 
have  a  nodulated  appearance  in  certain  parts,  from  the  membranes 
having  yielded  at  these  points  to  the  blood  which  may  have  escaped, 
or  to  the  pus  which  may  have  collected,  underneath.  Not  unfre- 
quently  small  collections  of  blood  are  met  with  in  the  softened  nerve 
tissue,  especially  in  the  position  of  the  central  vessel,  so  that  the  first 
impression  upon  opening  the  cord  may  be  that  of  hemorrhage  rather 
than  that  of  myelitis.  One  remarkable  feature  of  inflammatory  soften- 
ing, says  Dr.  Todd,  is  that  "it  exhales  a  marked  odour  of  sulphu- 
retted hydrogen,  and  so  indicates  a  rapid  advance  of  putrefaction ;" 
and  again,  "  It  is  a  fact  deserving  of  attention  that  the  substance  of  the 
spinal  cord  softens  very  rapidly  after  death,  the  lapse  of  half  an  hour, 
during  which  the  nervous  substance  has  been  exposed  to  the  air,  oftea 
producing  a  manifest  alteration."  Indeed,  there  are  reasons  for  be- 
lieving that  the  amount  of  disorganization  met  with  in  the  cord  after 
death  does  not  necessarily  represent  the  exact  amount  which  existed 
during  life,  and  that  a  cord  which  is  found  to  be  broken  up  after 
death  almost  utterly,  may  have  retained  during  life  sufficient  integrity 
to  allow  of  the  transmission  of  certain  sensitive  and  motor  impressions. 
On  this  view  the  return  of  slight  sensation  in  the  urethra  and  rectum 
shortly  before  death,  and  the  preservation  of  the  power  of  moving 
and  feeling  in  the  arms,  which  were  noticed  in  the  case  which  serves 
as  my  text,  are  not  altogether  unintelligible. 

Induration,  the  other  result  of  myelitis,  is  looked  upon  by  some  as 
a  stage  always  preceding  softening,  but  it  would  rather  seem  to  mark, 
as  Ollivier  supposed,  a  less  acute  form  of  inflammation.  In  it  the 
fibrinous  products  of  the  inflammation  seem  to  have  been  more  organ- 
izable.  The  cord  thus  indurated  varies  greatly  in  appearance;  it  may 
be  almost  as  pale,  bloodless,  crisp,  and  hard  as  cartilage ;  it  may  be 
more  or  less  red  and  vascular,  and  proportionably  softer;  and  in 
either  case,  when  examined  under  the  microscope,  its  proper  tissues 
are  found  to  be  broken  up  and  destroyed  almost  as  effectually  as  they 
are  when  the  cord  is  softened.  A  cord  which  is  indurated  has  usually 
a  shrunken  appearance,  but  it  may  be  swollen  considerably.  There 
is  no  doubt  an  induration  of  the  cord,  as  well  as  a  softening,  which 
cannot  be  referred  to  myelitis,  and  which,  must  not  be  confounded 
with  that  which  is  the  result  of  inflammation  ;  but  I  must  not  stay  to 
3 


34  DISEASES    OF    THE    SPINAL    CORD. 

point  out  the  differences,  nor  yet  to  do  more  than  say  that  in  myelitis 
there  will  in  all  probability  be  found,  in  addition  to  the  signs  which 
have  been  indicated,  engorgement  of  the  lungs,  kidneys,  and  other 
viscera,  possibly  more  marked  vascular  changes,  with  bed-sores,  cedema, 
dry  and  scurfy  skin,  wasted  muscles,  and  other  signs  of  defective 
nutrition  in  the  paralyzed  parts. 

3.  CAUSES. — Nothing  very  much  to  the  point  can  be  said  under 
this  head,  and  the  only  remark  I  feel  called  upon  to  make  is  this,  that 
as  in  spinal  meningitis  a  rheumatic  habit  has  been  found  to  figure 
more  or  less  conspicuously  among  the  causes  of  the  malady,  so  here  a 
like  position  would  seem  to  be  due  to  a  strumous  habit.    I  would  also 
confess  to  a  growing  impression  that  myelitis  may  not  unfrequently 
be  connected  more  with   excess  of  sexual  indulgence  than  with  any 
other  single  cause,  but  I  cannot  say  that  this  impression  has  yet  taken 
the  form  of  a  definite  conviction. 

4.  DIAGNOSIS. — In  dealing  with  the  symptoms  of  myelitis  it  has 
been  shown  that  these  are  very  different  from  those  of  spinal  menin- 
gitis— so  different  as  to  make  it  difficult  to  confound  them,  if  only 
moderate  care  be  taken  in  realizing  them.     In  spinal  meningitis  the 
most  prominent  symptom  is  pain  in  the  back  and  extremities,  pro- 
duced or  aggravated  by  movement;  in  myelitis  pain  of  any  kind  has 
scarcely  a  title  to  be  reckoned  among  the  symptoms,  pain  produced 
by  movement  certainly  not.     In  spinal  meningitis  the  sensibility  is 
somewhat  exalted,  in  myelitis  it  is  abolished.     In  spinal  meningitis 
there  is  muscular  weakness,  and  the  muscular  movements  are  fettered 
by  pain,  but  there  is  no  true  paralysis;  in  myelitis  paralysis  is  the 
symptom  of  symptoms.     In  spinal  meningitis  there  is  a  state  simu- 
lating trismus  and  tetanus,  a  state  of  muscular  rigidity  half  voluntary 
as  to  its  character,  of  which  the  object  is  to  prevent  certain  movements 
which  give  rise  to  pain ;  in  myelitis  the  muscles  are  limber,  and  there 
is  usually  an  utter  absence  of  any  symptom  akin  to  tremor,  convulsion, 
or  spasm. 

Nor  need  the  symptoms  of  common  paraplegia  (resulting  from 
chronic  myelitis)  be  confounded  with  those  of  locomotor  ataxy.  In 
common  paraplegia  there  is  paralysis  more  or  less  marked  of  the 
lower  extremities,  and  the  nutrition  and  irritability  of  the  paralyzed 
muscles  are,  as  a  rule,  unmistakably  impaired ;  not  so  in  locomotor 
ataxy.  In  common  paraplegia  the  paralysis  extends  to  the  bladder 
and  sphincter  ani,  and  the  sexual  power  is  greatly  weakened,  if  not 
altogether  abolished ;  not  so,  or  not  to  anything  like  the  same  degree, 
in  locomotor  ataxy.  In  common  paraplegia  the  characteristic  neural- 
gic pains  of  locomotor  ataxy  are  wanting,  and  numbness  is  nothing 
like  so  prominent  a  symptom  as  in  the  ataxic  disorder.  In  common 
paraplegia,  where  walking  is  possible,  the  gait — instead  of  being 
precipitate  and  staggering,  the  legs  starting  hither  and  thither  in  a 
very  disorderly  manner,  and  the  heels  coming  down  with  a  stamp  at 
each  step,  as  in  locomotor  ataxy — is  hampered  and  slow,  each  leg 
being  brought  forward  with  evident  difficulty,  even  with  the  help  of 
an  upward  hitch  of  the  body  on  the  same  side,  and  the  part  of  the 
foot  first  coming  in  contact  with  the  ground  being,  as  a  rule,  not  the 


MYELITIS.  35 

heel,  as  in  ataxy,  but  the  toes.  In  common  paraplegia  impairment 
of  sight  or  hearing,  or  strabismus,  or  ptosis,  or  injection  of  the  con- 
junctivas, or  contraction  of  the  pupils,  frequent  if  not  constant  sym- 
toms  in  locomotor  ataxy,  form  no  part  of  the  history.  In  fact,  in 
these  respects,  and  in  others  of  minor  importance  which  might  be 
mentioned,  the  histories  of  common  paraplegia  and  locomotor  ataxy 
are  so  different  that  it  is  not  easy  to  see  how,  with  only  a  moderate 
amount  of  care,  the  two  disorders  c^n  be  confounded. 

Now  and  then,  it  is  true,  instances  occur  in  which  it  is  not  so  easy 
to  distinguish  this  gait  of  common  paraplegia  from  that  of  locomotor 
ataxy — cases  in  which  the  weakened  muscles  contract  somewhat 
spasmodically  when  put  in  action,  and  in  which  there  is  often 
reason  to  believe  that  the  membranes  as  well  as  the  substance  of  the 
cord  are  affected,  but,  as  a  rule,  the  gait  in  common  paraplegia 
and  in  locomotor  ataxy  is  sufficiently  characteristic  to  make  it  diffi- 
cult to  confound  these  two  affections. 

In  cases  where  the  myelitis  is  confined  to  the  posterior  columns 
of  the  cord,  the  symptoms  will  be  those  of  locomotor  ataxy  rather 
than  those  which  have  been  ascribed  to  myelitis;  for,  so  far  as  the 
production  of  symptoms  is  concerned,  it  is  of  no  moment  whether 
the  disease  disorganizing  the  posterior  columns  be  inflammatory  or 
non-inflammatory,  acute  or  chronic  ;  and  in  other  cases  of  local 
myelitis  symptoms  are  sure  to  be  present  which  cannot  fail  to  lead 
to  a  correct  diagnosis,  if  what  was  said  in  the  preliminary  remarks 
upon  the  physiology  of  different  parts  of  the  spinal  cord  be  borne  in 
mind  in  interpreting  them.  Indeed,  with  what  is  now  known  of  the 
physiology  of  the  spinal  cord,  there  need  not  be  much  difficulty  in 
determining  the  whereabouts  of  local  mischief  in  the  cord. 

That  myelitis  cannot  well  be  confounded  with  other  spinal  disor- 
ders— spinal  congestion,  tetanus,  spinal  irritation,  and  the  rest — will 
be  seen  readily  enough  when  a  clear  idea  of  these  disorders  has  been 
realized,  and  only  then ;  and  this  being  the  case,  it  is  best  to  waive 
these  questions  in  diagnosis  until  the  fitting  opportunities  for  dealing 
with  them  present  themselves. 

5.  PROGNOSIS. — Acute  myelitis  affecting  any  considerable  extent  of 
the  spinal  cord  is,  without  doubt,  a  very  grave  disorder.     It  may  be 
fatal  in  fifteen  or  twenty  hours,  and  it  is  seldom  that  life  is  prolonged 
beyond  the  end  of  the  second  week.     Instances  of  recovery  are  on 
record,  it  is  true,  but  these  are  very  few  in  number,  and  of  them  there 
is,  perhaps,  no  single  one  in  which  the  correctness  of  the  diagnosis 
may  not  be  impugned.     Even  chronic  myelitis  is  a  very  grave  disease ; 
for  though  life  may  be  prolonged,  especially  where  the  disease  is  con- 
fined to  the  lower  part  of  the  cord,  the  mischief  once  done  seems  to 
be  in  a  great  measure  irremediable.     At  the  same  time  it  is  only  right 
to  say  that  of  late  years  the  results  of  treatment  have  been  much  more 
satisfactory,  and  that  it   is   possible  now  to    hope  where  there  was 
little  room  for  hoping  formerly. 

6.  TREATMENT. — There  appears  to  be  little  room  for  what  is  called 
active  treatment  even  in  acute  myelitis.     The  inflammation  is  evi- 


36  DISEASES    OF    THE    SPINAL    CORD. 

dently  of  a  very  low  type,  and,  reasoning  from  what  is  known  of  its 
beneficial  action  in  erysipelas  and  in  some  other  low  forms  of  in- 
flammation, it  seems  to  me  that  sesquichloride  of  iron  would  be  likely 
to  be  of  more  real  service  than  iodide  of  potassium.  Indeed,  I  should 
be  disposed,  until  I  know  of  a  better  plan,  to  trust  chiefly  to  full  doses 
of  this  preparation  of  iron,  to  food  and  wine  in  no  stinted  quantities, 
and  to  the  position  recommended  by  Dr.  Brown-Sequard  for  draining 
away  blood  from  the  spine — a  position  in  which  the  patient  is  made 
to  lie  upon  his  abdomen  or  side,  with  his  hands  and  feet  in  a  some- 
what dependent  position. 

With  respect  to  the  good  or  bad  effects  of  belladonna,  or  ergot,  or 
strychnia,  it  is  not  very  easy  to  arrive  at  a  satisfactory  conclusion.  I 
agree  with  Dr.  Brown-Se'quard,  in  thinking  that  belladonna  and  ergot 
may  have  the  effect  of  counteracting  a  hypersemic  condition  by  caus- 
ing contraction  in  the  vessels,  and  that  the  vessels  of  the  spinal  cord 
may,  perhaps,  respond  most  readily  to  their  action,  but  not  as  to  the 
indication  for  employing  these  remedies.  Pain  and  spasm  are,  to  Dr. 
Brown-Se'quard,  signs  of  hyperaemia :  to  me,  except  the  pain  produced 
by  movement,  they  are  signs  of  irritation  only — of  a  state  which  is 
connected,  not  with  hyperaemia,  but  with  anaemia,  a  state  of  contrac- 
tion of  the  vessels  which  may  pass  into  relaxation,  but  which  need 
not  necessarily  do  so;  and,  therefore,  to  me  pain  and  spasm,  instead 
of  being  indications  for  the  employment  of  belladonna  or  ergot,  are 
in  very  deed  centra-indications.  Nor  can  I  agree  in  thinking  that 
strychnia  acts  by  increasing  the  amount  of  blood  in  the  spinal  cord 
and  in  its  membranes,  and  that  on  this  account  it  is  contraindicated 
in  hyperaernic  conditions  of  these  parts.  Strychnia,  without  doubt, 
produces  tetanic  spasms  and  other  unequivocal  signs  of  spinal  irritation, 
but  it  is  begging  the  question  altogether  to  suppose  that  the  strychnia 
increases  the  amount  of  blood  in  the  cord  and  its  membrane,  that  this 
increase  of  blood  augments  the  vital  activity  of  the  cord,  and  that  the 
spasms  and  other  signs  of  irritation  attest  this  augmentation  of  vital 
activity.  Indeed,  so  far  from  this  being  a  necessary  conclusion,  all 
the  evidence  pointed  out  in  the  preliminary  remarks,  as  it  seems  to 
me,  points  in  the  opposite  direction,  and  connects  the  state  of  irritation 
of  which  the  spasms  are  the  signs,  not  with  a  hyperaemic  condition, 
but  with  an  anaemic;  and  most  assuredly  I  know  of  nothing  in  the 
history  of  myelitis  or  spinal  meningitis  which  is  calculated  to  invali- 
date this  conclusion.  Moreover,  the  investigations  of  Dr.  Harley 
upon  the  action  of  strychnia  upon  the  blood  go  to  show  that  this 
action  is  really  equivalent  to  loss  of  blood  in  that  it  directly  interferes 
with  the  proper  arterialization  of  the  blood.  In  a  word,  I  cannot  find 
any  fundamental  difference  between  the  action  of  belladonna,  ergot, 
and  strychnia  upon  the  bloodvessels,  neither  can  I  understand  why, 
strychnia,  properly  used,  might  not  be  of  as  much  service  as  bella- 
donna or  ergot,  in  lessening  a  hyperaemic  condition  of  the  cord.  For 
rny  own  part,  however,  I  confess  to  a  feeling  which  makes  me  hesitate 
to  employ  either  belladonna,  or  ergot,  or  strychnia  in  myelitis,  or  in 
any  analogous  condition,  until  I  know  more  of  their  action,  or  until  I 


MYELITIS.  37 

have  more  unequivocal  empirical  evidence  of  the  good  resulting  from 
their  use. 

In  chronic  cases  the  one  grand  indication  of  treatment,  as  it  seems 
to  me,  is  to  improve  the  nutrition  of  the  cord,  and  the  medicine  best 
calculated  to  carry  out  this  indication,  cod-liver  oil,  sesquichloride  of 
iron,  phosphorus  in  one  form  or  other,  arsenic,  and  possibly  bichloride 
of  mercury,  which  latter  preparation,  when  properly  used,  I  believe 
to  be  tonic  and  antiseptic  in  a  high  degree,  and  in  many  respects  much 
more  analogous  in  its  action  to  arsenic  than  to  any  of  the  photo-com- 
pounds of  mercury  in  common  use. 

The  local  means  for  promoting  the  recovery  of  the  paralyzed 
muscles  are  certainly  of  not  less  importance  than  the  general  means, 
possibly  of  much  greater  importance,  and  these  local  means  are  very 
various.  The  efficacy  of  frictions  and  shampooings  appears  to  be  indis- 
putable. The  efficacy  of  proper  movements  can  only  be  doubted  by 
those  who  are  unacquainted  with  the  results  arrived  at  by  the  "move- 
ment cure,"  and  by  systematic  movements  of  one  kind  or  another,  with 
or  without  the  help  of  mechanical  apparatus.  The  efficacy  of  faradi- 
zation has  been  abundantly  proved,  and  there  is  good  reason  to  believe 
that  this  is  not  the  only  mode  of  using  electricity  which  will  be  of 
great  service;  that  in  fact  statical  positive  electricity,  or  the  interrupted 
galvanic  current,  or  the  application  of  the  galvanic  current  in  such  a 
way  that  the  paralyzed  nerve  is  acted  upon  chiefly  by  the  positive  pole 
— a  mode  of  using  electricity  about  which  I  have  spoken  elsewhere, 
and  which  I  have  used  extensively  during  the  last  three  or  four  years 
— will  often  be  of  great  service  in  proper  cases.  Indeed  I  should  think 
that  the  treatment  was  wanting  in  very  essential  particulars  if  these 
local  means,  one  and  all,  were  not  associated  with  the  general  means 
of  treatment,  and  employed  systematically  and  perseveringly ;  and 
especially  I  should  regard  it  as  a  great  blunder  if  these  local  means  were 
deferred  so  as  to  allow  the  paralyzed  muscles  to  lose  what  when  lost  is 
not  easily  recovered — that  is,  their  irritability  and  healthy  organiza- 
tion. 

There  are  also  other  local  measures  which  are  of  great  service  in  the 
treatment  of  paralysis,  and  one  of  these  to  which  I  am  disposed  to 
attach  especial  importance  is  to  protect  the  paralyzed  parts  from  cold. 
In  many  cases,  as  is  well  known,  these  paralyzed  parts  are  cool,  and 
in  not  a  few  instances,  where  the  paralysis  is  incomplete  or  associated 
with  early  rigidity,  this  paralysis  and  rigidity  is  greatest  when  these 
parts  are  coldest.  For  example,  it  is  no  uncommon  thing  for  a  par- 
tially hemiplegic  patient  whose  paralyzed  fingers  are  contracted,  stiff, 
and  altogether  useless  when  acted  upon  by  cold,  to  be  able  to  open 
his  hand  and  use  his  fingers  with  comparative  freedom  when  the  hand 
is  warm  in  bed,  or  placed  in  a  warm  bath,  or  held  a  while  before  the 
fire.  At  any  rate,  I  have  long  been  satisfied  that  the  well  wrapping 
up  of  the  paralyzed  parts  in  woollen  or  silken  or  India-rubber 
coverings  is  an  important  help  in  treatment. 

It  would  also  seem  that  good  of  the  same  kind,  much  good,  may  be 
got  from  an  exhausting  apparatus  made  on  the  principle  of  Junot's 
boot.  The  effect  of  such  an  apparatus,  properly  used,  is  to  make  the 


38  DISEASES    OF    THE    SPINAL    CORD. 

paralyzed  parts  warmer  at  the  time,  and  to  enable  them  to  preserve 
this  warmth  for  a  considerable  time — to  produce  a  change  in  the  cir- 
culation, which  must  have  a  good  effect  upon  the  nutrition  and 
irritability  of  the  paralyzed  muscles. 

It  is  also  more  than  probable  that  electricity  may  be  of  service  in 
improving  the  condition  of  the  circulation  in  the  paralyzed  parts,  for 
an  increased  feeling  of  warmth  in  the  paralyzed  parts  is  the  result  of 
faradizing  these  parts,  or  of  electrifying  them  with  statical  electricity; 
indeed  I  have  been  more  than  once  disposed  to  think  that  the  benefi- 
cial effects  of  electricity  in  the  resuscitation  of  paralyzed  parts  are  as 
much  brought  about  indirectly  by  changes  produced  in  the  circulation 
as  by  changes  wrought  directly  in  the  nerves  and  muscles. 

As  regards  the  necessity  for  tenotomy  and  the  use  of  orthopasdic 
apparatus  in  certain  cases,  it  is  difficult  to  speak  to  any  good  purpose. 
I  shall  have  to  refer  to  these  subjects  when  speaking  of  infantile 
paralysis,  and  here  I  will  only  say,  that  in  many  cases,  in  children 
especially,  the  cure  will  be  greatly  facilitated  by  tenotomy  and  ortho- 
paedic apparatus,  and  that  it  is  not  always  easy  to  decide  between  the 
cases  in  which  these  measures  are  desirable  and  those  in  which  they 
are  not  desirable. 

IIT.  CONGESTION. 

Spinal  congestion,  or  plethora  spinalis,  is  not  less  definite  in  its 
history  than  myelitis  or  spinal  meningitis;  neither  is  it  of  less  prac- 
tical interest.  In  the  sequel,  indeed,  it  may  appear,  not  only  that 
spinal  congestion  is  fully  entitled  to  the  place  which  has  been  assigned 
to  it  in  the  catalogue  of  diseases,  but  also  that  it  really  comprehends 
more  than  one  spinal  disorder  which  is  now  known  under  a  different 
name. 

1.  SYMPTOMS. — As  an  instance  of  well-marked  spinal  congestion, 
I  take,  in  a  condensed  form,  the  notes  of  a  case  under  my  care  not 
long  ago. 

Case. — Mary  L.,  aged  28,  but  looking  very  much  older;  married, 
but  never  pregnant,  was  admitted  into  the  Westminster  Hospital  on 
the  12th  of  June,  1866. 

(a)  With  the  exception  of  being  able  to  turn  her  head  on  the  pil- 
low, and  to  move  the  fingers  and  toes  a  little,  all  power  of  voluntary 
movement  appears  to  be  wanting.  The  symptoms  chiefly  complained 
of  are  tingling  in  the  tips  of  the  fingers  and  toes,  a  dull,  burning 
aching  along  the  back  and  in  the  limbs,  arid  a  feeling  of  being  "tired 
to  death."  If  altered  in  anywise,  the  sensibility  to  touch,  pain,  tick- 
ling, and  differences  of  temperature  is  somewhat  more  acute  than 
natural.  The  spine  is  nowhere  tender  on  pressure,  but  the  dull,  burn- 
ing aching  in  this  region  is  increased  by  the  application  of  a  sponge 
soaked  in  hot  water.  The  soles  of  the  feet  may  be  tickled  without 
giving  rise  to  undue  reflex  movements.  The  bladder  and  bowels  act 
properly.  The  mind  is  not  at  all  affected.  The  state  generally  is  evi- 
dently one  of  great  exhaustion  and  prostration,  without  fever,  the 
pulse  being  quick,  unsteady,  and  very  compressible,  the  respiration 
shallow  and  curiously  interrupted  by  sighs. 


CONGESTION".  39 

(i)  Three  weeks  ago  menstruation,  which  had  only  just  begun,  was 
suddenly  checked  by  an  alarm  of  fire.  This  was  shortly  before  bed- 
time. The  next  morning,  after  a  very  sleepless  and  miserable  night, 
the  state  had  become  very  much  what  it  now  is.  Up  to  this  time  the 
patient  had  never  been  obliged  to  remain  in  bed  a  single  day  on. 
account  of  illness.  She  had  often  been  weak  and  ailing,  and  she  had 
suffered  a  good  deal  at  the  menstrual  periods  from  pain  and  weakness 
in  the  back  and  legs,  and  that  is  all.  She  also  appears  to  have  sprung 
from  a  tolerably  healthy  stock. 

(c)  Within  the  first  fortnight  after  admission  to  the  hospital,  the 
tingling  in  the  tips  of  the  fingers  and  toes  came  to  an  end,  and  so  did 
the  aching  in  the  back  and  limbs.  A  week  later  the  arms,  as  well  as 
the  hands,  could  be  moved  a  little.  At  the  end  of  six  weeks  the  legs 
remained  almost  as  helpless  as  at  first,  but  the  arms  and  trunk  had  so 
far  recovered  power  as  to  allow  of  a  change  from  the  lying  to  the  sit- 
ting posture  without  any  great  difficulty.  At  the  end  of  twelve  weeks 
it  was  possible  to  get  out  of  bed,  and,  with  the  help  of  a  stick,  to  move 
to  the  table  in  the  centre  of  the  ward.  On  the  3d  of  December,  five 
months  after  admission,  the  patient  left  the  hospital  convalescent.  All 
this  while  the  appetite  was  tolerably  good,  and  the  bladder  and  bowels 
acted  properly.  Now  and  then,  in  the  progress  towards  recovery, 
especially  about  the  menstrual  periods,  there  were  short  relapses,  in 
which  the  tingling  in  the  tips  of  the  fingers  and  toes,  and  the  aching 
in  the  back  and  lirnbs  came  back,  and  the  paralytic  weakness  of  the 
muscles  was  almost  as  great  as  at  first — in  which  the  ground  already 
gained  seemed  all  but  lost.  Now  and  then,  also,  the  nights  were  dis- 
turbed by  a  distressing  state  of  shortness  of  breath,  not  amounting  to 
asthma.  Before  the  legs  recovered  power  their  muscles  were  somewhat 
waste:!,  but  not  considerably  so;  indeed,  neither  here  nor  elsewhere 
was  the  paralysis  accompanied  by  any  marked  wasting  of  the  muscles 
or  by  any  appreciable  impairment  of  electro-sensibility  or  electro-con- 
tractility. Moreover,  any  movement,  whether  active  or  passive,  had 
always  the  effect  of  relieving  rather  than  of  increasing  the  aching  in 
the  back  and  limbs,  when  this  symptom  was  present.  The  treatment 
pursued  was  chiefly  rest,  good  living,  hypophosphite  of  soda,  nux 
vomica  now  and  then  in  small  doses,  cod-liver  oil,  and  faradization. 

Assuming,  as  I  well  may,  this  to  be  a  case  of  well-marked  spinal 
congestion,  I  take  as  points  of  comparison  between  it  and  other  cases 
of  the  kind,  general  and  partial,  these:  suddenness  of  access;  incom- 
plete paralysis  in  a  paraplegic  form ;  no  numbness;  tingling  in  the 
tips  of  the  fingers  and  toes ;  no  exaggeration  of  reflex  excitability  in 
the  paralyzed  limbs;  no  want  of  control  over  the  bladder  and  bowel; 
no  spinal  tenderness;  aching  in  the  back  increased  by  warmth;  pains 
in  the  back  and  limbs  not  increased  by  movement;  no  marked  im- 
pairment of  the  electro-contractility  and  electro-sensibility,  and  no 
material  wasting,  of  the  paralyzed  muscles;  no  feverishness ;  breath- 
lessness;  no  bed-sores;  proneness  to  relapses. 

Suddenness  of  onset. — To  be  well,  or  comparatively  well,  on  going 
to  bed,  and  to  be  paralyzed  in  the  morning,  as  in  the  case  which  £ 
have  given,  is  no  uncommon  thing  in  spinal  congestion.  It  is  indeed 


40  DISEASES    OF    THE    SPINAL    CORD. 

the  rule  rather  than  the  exception  for  the  illness  to  be  spoken  of  as 
a  "  stroke"  by  the  sufferer. 

Incomplete  paralysis  in  a  paraplegic  form. — Paralysis,  often  all  but 
complete,  but  never  quite  so,  and  taking  the  paraplegic  form,  must  be 
looked  upon  as  a  common  symptom  in  spinal  congestion.  The  paraly- 
sis is  decidedly  paraplegic  in  the  end,  and  it  may  be  so  from  the  begin- 
ning, but  not  unfrequently  one  leg  or  one  arm  is  affected  before  the 
other,  and  occasionally  the  leg  and  arm  of  the  same  side  may  for  a 
short  time  be  affected,  as  in  hemiplegia,  before  the  disease  extends  to 
the  leg  and  arm  of  the  other  side.  Not  unfrequently  there  remains  a 
difference  in  the  degree  of  paralysis  on  the  two  sides,  one  leg  or  arm 
being  more  affected  than  its  fellow.  Tn  cases  where  the  congestion 
of  the  cord  is  general  the  arms  as  well  as  the  legs  are  affected,  the 
former  perhaps  as  much  as  the  latter;  but  in  the  common  run  of  cases, 
where  the  congestion  is  confined  chiefly  to  the  lumbar  region  of  the 
spine,  the  legs  are  exclusively  or  chiefly  affected. 

No  anaesthesia. — Numbness  is  a  symptom  of  myelitis,  but  not  of 
spinal  congestion.  In  the  latter  disorder,  indeed,  instead  of  numbness 
there  is  occasionally  a  state  of  things  which  may  be  spoken  of  as  hyper- 
assthesia:  thus,  in  a  case  very  like  the  one  I  have  given,  which  came 
under  my  notice  in  private  practice  about  three  years  ago,  the  weight 
of  a  single  bed-sheet  was  distressingly  heavy  to  the  patient,  and  long- 
continued  aching  of  the  paralyzed  arms  and  legs  was  produced  by 
handling  them  ever  so  lightly. 

Tingling  in  the  tips  of  the  fingers  or  toes  of  the  paralyzed  limbs. — 
This  symptom  is  almost  always  present  at  one  time  or  other,  coming 
and  going  and  staying  a  longer  or  shorter  time,  often,  as  it  would  seem, 
very  capriciously.  One  is  glad  to  get  rid  of  it,  for  while  it  remains  it 
is  difficult  altogether  to  put  aside  the  fear  lest  the  state  of  the  cord 
should  pass  out  of  spinal  congestion  simple  into  the  graver  disease  of 
myelitis. 

No  exaggeration  of  reflex  excitability  in  the  paralyzed  limbs. — Increased 
disposition  to  reflex  movement  is  usually  regarded  as  one  of  the 
symptoms  in  spinal  congestion.  It  is  supposed  that  the  greater  afflux 
of  bl  )od  to  the  spinal  cord  must  bring  with  it  greater  reflex  excita- 
bility. I  believe,  however,  that  this  supposition  is  not  at  all  borne 
out  by  the  facts.  I  believe,  indeed,  that  the  moderate  reflex  excita- 
bility in  the  case  under  consideration  is  not  at  all  exceptional,  and 
that  it  is  the  rule  in  all  cases  of  spinal  congestion  for  this  manifestation 
of  muscular  contractility  to  be,  if  altered  at  all,  diminished  rather 
than  increased. 

No  paralysis  of  the  bladder  or  sphincter  ani. — In  myelitis,  paralysis 
of  the  bladder  or  sphincter  ani,  more  or  less  complete,  is  a  prominent 
symptom  :  in  spinal  congestion,  on  the  contrary,  these  symptoms  are 
absent,  except  in  those  mixed  cases  where  there  is  reason  to  believe 
that  some  degree  of  myelitis  is  also  present.  In  the  case  which  I  have 
given  there  was  not  the  least  want  of  control  over  the  bladder  or  bowel 
from  the  beginning  to  the  end. 

No  tenderness  on  pressure  along  the  spine. — Absence  of  spinal  tender- 
ness I  believe  to  be  the  invariable  rule,  not  only  in  spinal  congestion, 


CONGESTION.  41 

but  also  in  myelitis  and  spinal  meningitis.  I  believe,  indeed,  that 
spinal  tenderness  is  a  sign  of  the  presence  of  that  functional  disorder 
of  the  cord  which  is  usually  called  spinal  irritation,  and  that  it  does 
not  accompany  the  graver  diseases  of  the  cord  which  have  been  named 
when  they  are  uncomplicated  with  spinal  irritation.  Upon  this  sub- 
ject I  shall  have  more  to  say  presently. 

Dull  aching  along  the  spine  increased  by  ivarmth. — I  have  noticed  this 
symptom  in  three  cases  of  well-marked  general  spinal  congestion  which 
have  come  under  my  own  observation,  and  in  many  cases  of  partial 
congestion;  and  I  am  disposed  to  think  that  this  will  prove  to  be  one 
of  the  points  of  difference  between  spinal  congestion  and  spinal  irrita- 
tion. I  have  also  noticed  the  same  symptom  in  myelitis  and  spinal 
meningitis,  and  therefore  I  cannot  regard  it  as  having  any  special 
connection  with  spinal  congestion.  In  fact,  so  far  as  my  experience 
goes,  I  can  say  that  this  symptom  is  likely  to  be  met  with  in  conges- 
tive or  inflammatory  diseases  of  the  cord,  but  not  in  spinal  irritation 
simply ;  and  that  in  this  latter  case,  the  local  application  of  warmth, 
to  the  spine  is  more  likely  to  relieve  pain  than  to  cause  it. 

Pains  in  the  back  and  limbs  not  increased  by  movement. — This  sym- 
tom  has  some  claim  to  be  regarded  as  constant.  The  aching  would 
seem  to  go  and  come  with  the  congestion ;  and  the  fact,  for  fact  it 
seems  to  be,  that  it  is  not  increased  by  movement,  may  help  to  dis- 
tinguish spinal  congestion  from  spinal  meningitis,  for  in  the  latter 
affection  movement  of  the  limbs,  whether  passive  or  active,  is  attended 
with  pain  in  the  parts  moved  and  in  the  back. 

No  marked  impairment  of  electro-contractility  and  electro-sensibility  in, 
and  no  wasting  of,  the  paralyzed  muscles. — In  myelitis  the  paralyzed 
muscles  are  prone  to  waste  and  to  lose  their  electro-contractility  and 
electro-sensibility,  and  herein,  therefore,  would  seem  to  be  a  marked 
difference  between  this  disorder  and  spinal  congestion;  for,  so  far  as 
I  know,  the  contrary  state  of  things  invariably  holds  good  in  spinal 
congestion.  In  speaking  thus,  however,  it  must  not  be  forgotten 
that  all  muscles  which  remain  paralyzed  eventually  lose  their  irrita- 
bility and  struction;  and  this  equally,  whether  the  paralyzing  cause 
be  myelitis,  spinal  congestion,  or  other. 

No  feverishness. — This  is  no  special  feature ;  indeed,  fever  would 
seem  to  have  little  to  do  with  any  affection  of  the  cord,  not  even  ex- 
cepting meningitis  in  its  most  active  form. 

No  bed-sores. — A  marked  disposition  to  bed-sores  would  seem  to  be 
the  rule  in  myelitis,  but  not  so  in  spinal  congestion  or  spinal  menin- 
gitis. Upon  this  point,  more  than  upon  many  others,  there  is  tolerable 
unanimity  of  opinion. 

Shortness  of  breath. — Where  the  spinal  congestion  is  at  all  general, 
this  state  of  things  may  be  readily  accounted  for  by  the  paralytic 
weakness  of  muscles  concerned  in  respiration.  In  the  case  which 
serves  as  my  text,  the  occasional  shortness  of  breath  is  noticed  as  not 
amounting  to  asthma;  and  this  is  a  point  of  some  interest,  for  it  may 
be  supposed  that  the  difficulty  of  breathing  would  have  taken  this 
form — would  have  had  something  of  a  decidedly  spasmodic  character 


42  DISEASES    OF    THE    SPINAL    CORD. 

— if  the  congested  condition  of  the  cord  involved,  as  it  is  supposed  to 
do,  an  exaggeration  of  reflex  excitability. 

Proneness  to  relapse. — Whether  this  may  prove  to  be  a  constant 
feature  in  spinal  congestion  remains  to  be  seen.  That  it  is  not  an 
uncommon  one  is  to  me  an  indisputable  fact. 

Spinal  congestion  varies  greatly  in  its  degree,  and  in  the  extent  of 
cord  implicated.  Limited  to  the  lumbar  region,  and  carried  to  a  degree 
which  produces,  not  paralysis,  but  weakness  more  or  less  approaching 
to  paralysis  in  the  legs,  it  is  common  enough ;  indeed,  many  women 
seem  to  suffer  from  it  before  every  menstrual  period ;  and  between 
this  partial  and  incomplete  form  and  the  general  and  complete  form, 
of  which  the  case  which  has  been  given  is  an  instance,  there  are  all 
possible  grades  of  transition.  It  would  seem  to  be  most  common  in 
women,  but  it  is  not  peculiar  to  the  female  sex  or  to  any  age.  The  onset 
of  the  disorder  is  generally  sudden,  in  relapses  as  well  as  in  original 
attacks;  and  the  cases  do  not  at  all  divide  themselves  into  acute  and 
chronic  as  do  the  cases  of  many  other  disorders. 

2.  POST  MOKNSM  APPEARANCES. — These  appearances  are  very  vague 
and  unsatisfactory,  at  most  being  simply  some  engorgement  of  the 
veins  of  the  spinal  cord  and  membranes,  with  some  excess  of  the 
spinal  fluid,  both  of  which  phenomena,  as  will  be^  easily  understood, 
are  not  very  unlikely  to  escape  detection  unless  the  post-mortem  exami- 
nation be  conducted  with  unusual  care.     With  the  exception  of  this 
engorgement  and  serous  effusion,  the  only  morbid  sign  which  has  been 
noticed  (and  this  by  no  means  constantly)  is  slight  infiltration  with 
blood  of  the  cellular  tissue  exterior  to  the  dura  mater.    In  all  uncom- 
plicated cases,  the  structure  of  the  cord  and  of  its  membranes  is  in 
nowise  altered. 

3.  CAUSES. — As  in  the  case  which  I  have  given,  the  suppression  of 
the  catamenia  would  seem  to  figure  most  conspicuously  among  the 
causes  of  spinal  congestion,  and  next  to  this  the  cessation  of  hemorrhage 
from  piles.     Beyond  this  it  is  difficult  to  single  out  any  one  cause 
which  has  a  just  claim  to  be  considered  as  at  all  special :  and,  for  the 
rest,  nothing  further  need  be  said  except  this — that  spinal  congestion 
is  not  unfrequently  a  consequence  of  pulmonary  or  abdominal  con- 
gestion or  inflammation — a  consequence,  perhaps,  which   has   often 
more  to  do  in  compromising  the  safety  of  the  patient  than  the  primary 
disorder  itself. 

4.  DIAGNOSIS. — Paraplegic  paralysis  is  a  symptom  common  to  spi- 
nal congestion  and  myelitis,  with  this  difference,  that  it  is  less  complete 
in  the  former  affection  than  in  the  latter.     The  paralysis  is  associated 
with  anaesthesia  in  myelitis;  not  so  in  spinal  congestion.     The  control 
of  the  bladder  and  bowels  is  lost  in  myelitis ;  not  so  in  spinal  conges- 
tion.    The  paralyzed  muscles  are  prone  to  waste  and  lose  their  electro- 
contractility  and  electro-sensibility  in  myelitis;   not  so  in  spinal  con- 
gestion.    The  imperfect  paralysis  and  the  absence  of  anaesthesia  would 
seem,  indeed,  to  connect  spinal  congestion    more  closely  with  spinal 
meningitis  than  with  myelitis,  and  so  also  would  the  pain  in  the  back 


TETANUS.  43 

and  aching  in  the  limbs;  but  the  pain  and  aching  in  spinal  congestion 
cannot  well  be  confounded  with  the  pain  which  is  met  with  in  spinal 
meningitis,  for  the  pain  in  this  latter  affection  is  produced  by  move- 
ment and  accompanied  by  rigidity,  whereas  the  pain  in  the  former 
affection  is  not  produced  and  accompanied  in  this  manner.  Hysterical 
paralysis,  so  called,  agrees  with  the  paralysis  depending  upon  spinal 
congestion  in  some  respects  but  not  in  others.  It  agrees  in  that  the 
paralyzed  muscles  are  neither  prone  to  waste  nor  to  lose  their  electro- 
contractility  ;  it  disagrees  in  that  numbness  is  a  prominent  symptom, 
more  prominent  even  than  the  paralysis,  and  that  the  electro-sen- 
sibility of  the  paralyzed  muscles  is  either  annihilated  or  very  much 
diminished. 

5.  PROGNOSIS. — Eecovery  is  the  rule,  no  doubt,  in  cases  of  spinal 
congestion,  but  there  is  no  difficulty  in  finding  cases  in  which  the 
disease  has  been  fatal,  and  quickly  fatal  too.     In  the  partial  form, 
affecting  the  lumbar  portion  of  the  cord  only,  spinal  congestion  may 
come  and  go  quickly  without  any  great  damage  being  done;  but  in 
the  cases  in  which  the  cord  is  more  extensively  and  more  profoundly 
affected,  as  in  the  case  which  has  been  cited,  recovery  may  occupy  a 
considerable  time.     Thus,  of  the  cases  recorded  by  Ollivier,  No.  55 
remained  in  hospital  nearly  five  months,  No.  56  two  months,  No.  57 
three  months,  and  No.  58,  "  assez  longtemps."     Kecovery  is  slow,  as  it 
would  seem,  because  time  is  required  for  the  absorption  of  the  excess  of 
spinal  fluid  to  which  the  state  of  spinal  engorgement  had  given  rise. 

6.  TREATMENT. — What  has  been  said  respecting  myelitis  must  be 
supposed  to  apply  here  equally.     Indeed,  the  only  special   remark 
which  appears  to  be  called  for  in  this  place  is  this — that  in  cases 
where,  as  very  generally  it  happens,  the  spinal  congestion  can  be  referred 
to  suppression  of  a  menstrual  or  haemorrhoidal  discharge,  the  primary 
indication  would  appear  to  be  the  setting  up  of  an  equivalent  discharge 
by  applying  leeches  to  the  os  uteri  or  to  the  anus. 

IV.  TETANUS. 

Tetanus  is  unhappily  no  rare  or  unfamiliar  malady.  The  name, 
from  teivu,  I  stretch,  refers  to  that  rigid  and  cramped  condition  of  the 
muscles  which  is  the  most  characteristic  symptom,  and  which,  in 
sober  earnest,  is  suggestive  of  rigor  mortis,  not  only  in  posse  but 
actually  in  esse  •  for  there  are  some  cases  in  which,  without  any 
interval  of  relaxation,  tetanic  rigidity  at  once  passes  into  cadaveric 
rigidity.  Hydrophobia  alone  excepted,  tetanus  is  at  once  the  most 
appalling  and  the  most  perilous  of  all  spasmodic  diseases. 

1.  SYMPTOMS. — As  an  instance  of  well-marked  tetanus,  I  take  the 
notes  of  such  a  case  which  I  happened  to  see  from  the  beginning  to 
the  end  about  six  years  ago. 

Case. — Patrick  M ,  a  fair,  slightly-built,  delicate-looking  man, 

unmarried,  aged  27,  the  coachman  of  a  gentleman  then  under  my 
care.  On  the  21st  of  April,  1861,  as  I  was  leaving  the  house  of  his 
master,  I  found  him  in  the  hall,  and  he  took  the  opportunity  of  saying 


44  DISEASES    OF    THE    SPINAL    CORD. 

that  he  was  not  well  enough  to  bring  round  the  carriage,  and  of 
asking  me  what  he  had  better  do.  What  he  complained  of  chiefly 
were  a  stiff  neck  and  sore  throat,  with  a  feeling  of  weakness  and  illness. 
The  stiff  neck  and  sore  throat  made  their  appearance  for  the  first  time 
this  day;  the  feeling  of  illness  and  weakness  have  been  present  for  the 
last  three  days.  The  mouth  cannot  be  opened  so  as  to  allow  a  fair 
look  at  the  tongue,  and  a  meal,  it  appears,  has  just  been  left  unfinished, 
not  for  want  of  appetite,  but  simply  on  account  of  the  difficulty 
experienced  in  masticating  and  swallowing  the  morsels.  There  is  no 
feverishness. 

P.  M ascribes   his   present   indisposition  to   having  been  out 

with  the  carriage  several  hours  in  the  wet  and  wind  three  nights  ago, 
and  he  says  further  that  he  is  liable  to  colds.  Before  speaking  to  me, 
he  had  taken  some  opening  medicine  which  a  chemist  had  prescribed 
and  prepared  for  him,  and  he  thinks  that  this  dose  may  account  for 
the  fact  of  feeling  so  ill  and  weak  at  the  present  moment.  Some  sim- 
ple treatment  was  recommended,  and  I  took  my  leave,  not  at  all 
divining  what  was  so  soon  to  follow. 

April  22. — Receiving  information  that  this  poor  fellow  was  not  so 
well,  I  went  round  to  see  him  at  his  lodgings.  I  found  him  strangely 
altered.  His  teeth  were  firmly  and  inseparably  clenched,  and  he 
looked  literally  like  an  old  man — so  like,  that  his  mother,  who  lived 
with  him,  said  that  she  could  have  thought  his  father  had  come  back 
to  life  if  only  his  hair  had  been  gray.  His  voice  hud  also  become  so 
low  and  indistinct  as  to  make  it  difficult  to  catch  what  he  said.  The 
medicine  given  by  the  chemist  yesterday,  it  appears,  has  purged  him 
violently  several  times  in  the  night,  and  more  than  once  while  at  stool 
he  has  been  seized  with  acute  pain  in  the  pit  of  the  stomach,  which 
took  away  his  breath,  and  made  him  think  he  was  going  to  die.  It 
was  in  the  night,  while  at  stool,  that  the  jaws  became  closed.  I  wished 
him  to  go  to  the  hospital,  and  he  was  willing  to  do  so,  but  his  mother 
would  not  consent.  Eggs  beaten  up  with  brandy  were  ordered  to  be 
given  repeatedly,  and  every  three  hours  a  draught  containing  five 
grains  of  quinine  and  half  a  drachm  of  Hoffmann's  anodyne.  I  now 
noticed  on  one  of  the  fingers,  which  was  tied  up  in  a  piece  of  rag,  a 
small  wound,  healing  and  apparently  healthy,  the  result  of  a  tear  by 
a  rusty  nail  about  a  fortnight  ago. 

On  a  second  visit,  later  in  the  day,  I  found  that  repeated  attempts 
had  been  made  in  the  interval  to  give  the  food  and  medicine,  but  with 
very  trifling  success.  There  was  no  great  difficulty  in  getting  the  food 
or  medicine  into  the  mouth,  for  almost  all  the  teeth  on  the  right  side 
were  gone,  but  the  attempt  to  swallow  brought  on  spasm  in  the  throat, 
and  on  more  than  one  occasion  the  spasm  forced  the  greater  part  of 
what  was  taken  back  through  the  nostrils.  And  this  difficulty  was 
all  the  more  distressing,  because  a  feeling  of  hunger  prompted  the 
patient  of  his  own  accord  to  make  frequent  attempts  to  swallow.  The 
chief  complaint  now  was  of  a  dragging  pain  at  the  pit  of  the  stomach, 
piercing  through  to  the  back.  In  answer  to  a  question  whether  he 
could  sit  up  in  bed,  he  said,  "I  think  T  am  too  stiff  to  do  so,"  and 
then  he  tried  to  sit  up,  and  succeeded  after  making  two  or  three 


TETANUS.  45 

abortive  attempts.  While  sitting  up  I  found  that  he  could  scarcely 
move  his  head,  and  that  the  muscles  of  the  neck  and  back  were  very 
stiff  and  hard.  I  had  only  just  noticed  these  phenomena  when  the 
noise  caused  by  the  upsetting  of  a  chair  brought  on  a  fit  of  spasm,  in 
which  the  patient  was  suddenly  thrown  backwards  upon  the  bed  with 
considerable  force,  and'left  resting  upon  his  head  and  heels,  in  a  state 
of  complete  opisthotonos — a  state  so  complete  as  to  make  it  possible 
for  me  to  pass  my  hand  under  the  loins  without  touching  either  the 
body  or  the  bed.  This  severe  spasm  lasted  not  less  than  a  couple  of 
minutes,  and  the  only  muscles  which  did  not  seem  to  be  implicated 
in  it  were  the  abdominal,  those  of  the  arms  and  hands,  and  those  of 
the  eyeball.  In  this  spasm  the  complexion  became  dusky  and  livid, 
and  the  features  altered  in  a  frightful  manner,  the  angles  of  the  mouth 
being  drawn  upwards  and  outwards  so  as  to  give  the  expression 
known  as  the  risus  sardonicus,  the  set  teeth  being  slightly  uncovered, 
the  nostrils  spread,  the  eyes  staring  and  prominent,  the  brow  knit,  the 
hair  bristling — the  complexion  and  features  became  changed,  that  is 
to  say,  as  they  are  changed  in  sudden  suffocation.  All  this  while,  too, 
the  skin  generally  was  dusky  and  hot  and  drenched  in  perspiration. 
For  some  time  after  this  spasm  had  passed  off  the  patient  remained 
moaning,  and  unable  to  speak  audibly,  and  then  he  said,  "That  pain 
will  kill  me  if  it  comes  back."  I  noticed,  also,  that  there  remained  after 
this  spasm  a  state  of  tetaniform  rigidity  and  contraction,  by  which  no 
inconsiderable  degree  of  opisthotonos  was  still  kept  up.  The  eggs 
and  brandy  and  the  medicine  were  ordered  to  be  given  by  enema. 

April  23. — Two  attempts  were  made  to  administer  the  enemata 
ordered  over  night  without  success,  the  irritation  of  the  pipe  in  each 
instance  bringing  on  a  fit  of  spasm;  indeed,  all  that  it  has  been 
possible  to  give  since  my  last  visit  have  been  a  few  sips  of  wine  and 
water.  There  has  been  no  sleep  whatever  during  the  night.  During 
the  last  eighteen  hours  several  fits  of  spasm  like  the  one  described 
have  occurred,  and  the  permanent  rigidity  and  contraction  remaining 
between  the  fits  have  increased.  The  abdominal  muscles,  which  were 
not  at  all  implicated  yesterday,  are  now  as  hard  and  stiff  as  those  of 
the  neck,  back,  and  legs.  The  pulse  is  quick  (about  140),  weak,  and 
somewhat  irregular ;  the  breathing  is  shallow,  hurried,  and  frequently 
checked  by  gasps  and  catches,  even  when  it  is  not  interrupted  by  the 
fits  of  spasm. 

No  material  change  has  taken  place  since  the  morning.  On  one 
occasion  in  the  course  of  the  day  an  egg  beaten  up  with  some  brandy 
has  been  swallowed,  but  all  other  attempts  to  administer  food  or  medi- 
cine, whether  by  the  mouth  or  by  the  rectum,  have  been  rendered 
abortive  by  the  fits  of  spasm  to  which  they  gave  rise. 

April  24. — Again  the  night  has  passed  without  sleep,  and  to-day 
the  constant  tetaniform  contraction  has  become  almost  universal.  In 
fact,  the  only  muscles  which  are  not  obviously  affected  are  those- of 
the  hands,  and  tongue,  and  eyeball.  The  fits  of  spasm,  also,  are  now 
more  frequent  and  severe,  being  not  more  than  fifteen  or  twenty 
minutes  apart,  and  lasting  until  death  from  suffocation  seems  even 
more  than  imminent;  they  are  brought  on  by  the  most  trivial  causes 


46  DISEASES    OF    THE    SPINAL    CORD. 

— an  attempt  to  swallow,  a  draught  of  air,  the  simple  straightening  of 
the  bedclothes — or  they  come  on  without  any  apparent  cause.  There 
is  no  improvement  in  the  breathing  and  pulse,  but  if  anything  a 
change  for  the  worse.  During  the  fits  the  skin  is  hot,  dusky,  and 
drenched  in  perspiration:  in  the  intervals  it  has  an  ominous  coolness 
and  clamminess.  The  mouth  is  full  of  viscid  frothy  saliva,  and  there 
is  much  thirst.  While  I  was  present  a  small  quantity  of  dark  urine 
was  passed  slowly  and  with  some  difficulty,  and  this  appears  to  be  the 
only  time  the  bladder  has  acted  for  at  least  twenty -four  hours.  The 
pupils  are  large,  especially  in  the  paroxysms. 

Shortly  before  I  went  again  at  the  end  of  the  day,  there  had  been 
a  momentary  snatch  of  sleep,  which  had  been  abruptly  brought  to  an 
end  by  an  attack  of  opisthotonos,  in  which  the  tongue  or  cheek  had 
been  bitten,  and  now  the  frothy  viscid  saliva  which  filled  the  mouth 
to  overflowing  was  deeply  crimsoned  with  blood — a  ghastly  addition 
to  a  countenance  already  overcharged  with  horrors.  During  the  last 
six  hours  the  parox}7sms  have  been  less  frequent  and  severe,  but  the 
vital  powers  are  evidently  fast  ebbing  away.  "  I  cannot  get  my 
breath,"  was  the  answer  slowly  and  almost  inarticulately  given  to  the 
question,  "Have  you  much  pain?" 

Death  happened  about  midnight,  an  hour  after  I  had  taken  my 
leave,  after  a  paroxysm  of  opisthotonos  of  no  special  violence,  brought 
on,  as  it  would  seem,  by  an  attempt  to  wipe  away  the  bloody  saliva 
from  the  lips.  When  I  left  the  rnind  was  perfectly  clear  and  collected, 
and  at  no  time,  either  before  or  after,  was  it  otherwise. 

For  the  rest  it  only  remains  to  add  (for  the  objections  made  to  a 
post-mortem  examination  were  insuperable)  that  the  countenance 
appears  to  have  retained  after  death  the  aged  expression  it  had  before 
death,  and  that  the  corpse  when  "  laid  out"  was  found  to  have  stiffened 
without  losing  altogether  the  opisthotonic  attitude.  The  mother  of 
the  patient  is  my  only  authority  upon  these  points,  for  unfortunately 
it  did  not  occur  to  me  to  make  inquiries  respecting  them  before  the 
funeral  had  taken  place. 

In  order  to  realize  the  points  of  resemblance  and  difference  between 
this  case  and  other  cases  of  the  kind,  the  course  I  propose  to  pursue 
is  to  take  one  after  the  other,  as  the  points  demanding  attention, 
these — permanent  muscular  contraction,  beginning  by  causing  tris- 
rnus,  ending  by  causing  opisthotonos,  and  implicating  when  at  its 
height  almost  all  the  voluntary  muscles  except  those  of  the  hands,  the 
eyeball,  and  the  tongue ;  pain  at  the  pit  of  the  stomach  piercing 
through  to  the  back;  difficulty  of  swallowing  from  the  occurrence  of 
spasm;  fits  of  painful  spasm  in  the  permanently  contracted  muscles  ; 
risus  sardonicus,  and  an  aged  expression  of  countenance,  apnoea  in 
the  fits  of  spasm,  and  more  or  less  dyspnoea  at  other  times ;  profuse 
perspiration  in  the  fits  of  spasm,  with  heat  of  skin;  increased  reflex 
excitability  ;  absence  of  fever ;  absence  of  sleep  ;  absence  of  numbness 
or  tingling;  absence  of  "  head  symptoms ;"  no  marked  want  of  control 
over  the  bladder  and  bowels;  comparative  voicelessness;  the  mouth 
clogged  with  viscid  frothy  saliva ;  a  bitten  tongue  or  cheek ;  dilatation 


TETANUS.  47 

of  pupils;  absence  of  priapism ;  presence  of  a  wound;  death  by 
apnoea;  early  if  not  immediate  rigor  mortis. 

Permanent  muscular  rigidity,  causing,  first,  trismus,  then  opisthotonos, 
and  implicating,  when  at  its  height,  almost  all  the  voluntary  muscles 
except  those  of  the  hands,  the  eyeball,  and  the  tongue. — Muscular  rigidity, 
continuing  without  any  marked  relaxation  from  the  time  of  its  first 
appearance,  is  the  most  characteristic  symptom  of  tetanus.  It  would 
seem  to  be  the  rule  for  this  state  of  stiffness  to  begin  in  the  muscles 
of  the  jaws,  causing  trismus,  and  to  extend  from  thence  as  a  centre, 
first  to  the  muscles  of  the  face  and  neck,  then  to  those  of  the  back, 
causing  opisthotonos,  then  to  those  of  the  lower  extremities,  and,  lastly, 
to  those  of  the  upper  extremities,  the  progress  in  both  extremities 
being  from  above  downwards;  but  there  are  exceptions  to  this  rule, 
for  a  few  cases  are  on  record  in  which  the  muscles  of  the  neck  have 
been  affected  before  those  of  the  jaws,  and  others,  also  only  few  in, 
number,  where  the  muscles  near  a  wound,  as  of  a  stump  after  ampu- 
tation, have  been  the  first  to  become  rigid.  Even  in  the  most  extreme 
cases,  the  hands  and  the  tongue  are  found  to  remain  limber,  and  it  is 
but  very  rarely,  except  perhaps  in  children  with  "head  symptoms"  in 
addition  to  the  ordinary  phenomena  of  tetanus,  that  a  squint  or  a 
fixed  stare  shows  that  the  deep  muscles  of  the  orbit  are  affected.  Fits 
of  spasm,  of  which  more  will  have  to  be  said  presently,  may  seize 
upon  the  tongue,  as  they  do  very  frequently  upon  the  muscles  of  the 
throat  in  attempts  to  swallow,  but  there  is  no  proof  that  either  the 
tongue  or  the  muscles  of  the  throat  are  ever  in  a  state  of  permanent 
contraction.  Neither  is  there  any  certain  proof  that  the  heart  or 
other  involuntary  muscles  are  in  any  degree  permanently  contracted. 
The  affected  muscles  are  very  hard,  curiously  so,  feeling  very  much 
as  they  do  in  rigor  mortis,  and  they  are  not  unfrequently  some- 
what tender  when  pressed  or  squeezed.  In  the  great  majority  of 
cases,  without  question,  the  first  effect  of  tetanic  rigidity  is  to  close 
the  jaws  and  cause  trismus,  and  the  next  to  bend  the  body  backwards 
and  produce  opisthotonos.  Opisthotonos,  indeed,  is  almost  as  charac- 
teristic and  constant  a  result  as  trismus.  Now  and  then,  it  is  true, 
instead  of  the  body  being  bent  backwards  it  may  be  bent  forwards 
(emprosthotonos),  or  sideways  (pleurosthotonos),  but  these  cases  are 
quite  exceptional,  and  opisthotonos  may  in  reality  be  looked  upon 
as  the  position  which  the  body  always  takes  or  tends  to  take  in 
tetanus. 

Pain  at  the  pit  of  the  stomach  piercing  through  to  the  back. — This  is 
reckoned  by  the  late  Dr.  Chambers  as  the  pathognomoriic  symptom  of 
tetanus,  and  in  fact  it  is  scarcely  ever  absent,  not  even  at  the  very 
beginning.  This  pain  is  especially  severe  in  the  fits  of  spasm,  and 
then  it  is  often  agonizing,  but  it  is  present  also,  if  not  in  a  severe,  at 
least  in  a  mitigated  form,  in  the  intervals  between  these  fits,  scarcely 
ever  ceasing  altogether,  even  for  a  moment,  when  once  it  has  made  its 
appearance.  It  depends,  there  is  little  reason  to  doubt,  upon  the  dia- 
phragm being  implicated  in  the  tetanic  condition.  Once  it  was  looked 
upon  as  a  certain  death-warrant,  but  this  opinion,  as  Mr.  Curling  haa 
shown,  is  untenable. 


48  DISEASES    OF   THE    SPINAL    CORD. 

Difficulty  of  swallowing  from  tJie  occurrence  of  spasm. — This  spasm, 
which  is  provoked  by  the  attempt  to  swallow,  may  be  in  the  pharynx 
or  gullet,  or  in  the  cardiac  aperture  of  the  diaphragm,  one  or  all, 
making  swallowing  impossible,  and  often  leading  to  the  violent  ejection 
of  fluids  through  the  nose  or  from  the  mouth.  The  distress  consequent 
upon  it  may  sometimes  cause  a  horror  of  liquids  not  unlike  that 
which  exists  in  hydrophobia,  and  it  always  constitutes  a  grave 
difficulty,  for  it  not  only  incapacitates  the  patient  from  feeding  in  the 
usual  way,  but  it  prevents  him  from  being  fed  by  means  of  the 
stomach-pump. 

Fits  of  painful  spasm  in  the  permanently  contracted  muscles. — These 
fits  become  more  frequent  as  well  as  more  violent  and  painful  as  the 
disease  progresses,  recurring  when  at  the  worst  every  ten  or  fifteen 
minutes,  and  lasting  from  one  to  two  and  a  half  minutes.  So  violent 
has  been  the  muscular  contraction  in  some  of  these  fits,  that  the  teeth 
and  thigh  bones  have  been  broken,  and  great  muscles  like  the  psoas 
and  recti  femorales  torn  across.  These  fits  of  spasm  are  almost  inva- 
riably very  painful,  the  pain  being  that  of  cramp,  but  now  and  then 
the  pain  has  been  absent:  thus,  Sir  Gilbert  Blane  mentions,  on  the 
authority  of  a  surgeon  in  the  navy,  a  case  of  severe  tetanus,  fatal  in 
four  days,  in  which  the  fits  of  spasm  only  gave  rise  to  a  sort  of 
pleasurable  tingling;  and  Mr.  Curling  instances  an  analogous  case. 
Most  generally  the  pain  in  the  fit  of  spasm  is  felt  chiefly  at  the  pit  of 
the  stomach,  and  very  often  the  pain  in  this  region  may  be  so  ago- 
nizing and  stifling  as  to  make  the  patient  insensible  to  pain  elsewhere. 
Sometimes  the  pain  in  the  neighbourhood  of  a  wound,  as  in  the 
stump  after  amputation,  is  that  which  is  most  complained  of. 

Risus  sardonicus  and  an  aged  expression  of  countenance. — The  sneering 
expression,  caused  by  the  angles  of  the  mouth  being  drawn  back- 
wards and  upwards,  and  known  as  the  risus  sardonicus,  in  association 
with  spread  nostrils,  staring  and  prominent  eyes,  knitting  of  the  brows, 
and  bristling  of  the  hair,  is  so  often  present  as  to  be  properly  reck- 
oned as  pathognomonic  of  tetanus.  In  the  fits  of  spasm  the  lips  are 
often  drawn  apart  so  as  to  expose  the  set  teeth,  but  sometimes  they 
are  kept  tightly  pressed  together  by  the  spasmodic  action  of  the 
orbicularis  oris.  The  aged  expression  which  was  present  in  the  case 
I  have  given,  is  exceptional,  but  it  has  been  met  with  in  other  cases. 
Thus,  Mr.  Curling  refers  to  a  case  of  idiopathic  tetanus,  related  by 
Dr.  W.  Farr,  in  which  the  patient,  who  was  only  twenty  six  years  of 
age,  looked  at  least  sixty;  and  he  says  further  that  he  himself  has 
"  observed  the  same  circumstance  in  an  equally  remarkable  degree." 

Dyspnoea  with  fits  of  comparative  apnoea. — When  tetanus  is  fully 
developed,  an  apprehension  of  suffocation  is  often  present  even  in  the 
intervals  between  the  fits  of  spasm,  and  in  these  fits  the  suffused  eyes, 
the  livid  countenance,  and  the  agonizing  struggle  for  breath  show 
plainly  enough  that  this  is  in  no  sense  a  groundless  fear.  How  this 
difficulty  is  brought  about  is  not  easy  to  say,  and  probably  the  way  is 
not  always  the  same.  Sometimes  spasmodic  closure  of  the  glottis 
would  seem  to  be  a  prominent  cause;  sometimes  the  thorax  is,  as  it 
were,  held  in  a  vice  by  the  spasm  of  all  its  muscles  generally ;  must 


TETANUS.  49 

commonly  perhaps  these  two  causes  act  together.  From  my  own 
small  experience  I  should  be  disposed  to  attach  less  importance  to  the 
last  cause  than  to  the  first,  and  I  question  whether  much  relief  would 
be  obtained  in  any  case  by  carrying  out  Marshall  Hall's  suggestion  of 
opening  the  windpipe  in  cases  of  tetanus. 

Increased  reflex  excitability. — In  P.  M ,  as  the  disease  advanced, 

the  fits  of  spasm  were  brought  on  by  the  most  trivial  causes — a  draught 
of  air,  a  sudden  noise,  an  attempt  to  swallow,  an  attempt  to  administer 
an  injection,  the  arrangement  of  the  bed-clothes,  the  lightest  touch 
even — and  hence  it  may  be  inferred  that  increased  reflex  excitability- 
was  an  element  in  this  case.  Nor  is  this  case  at  all  exceptional  in  this 
respect.  As  the  disease  advances,  in  fact,  the  controlling  influence  of 
the  nervous  system  is  removed,  and  this  is  all,  for  what  are  counted  as 
signs  of  increased  reflex  excitability  are  in  reality  no  more  than  signs 
of  nervous  exhaustion,  such  as  manifest  themselves  whenever  the  vital 
powers  are  sufficiently  lowered  by  loss  of  blood,  or  in  any  other  way. 

Profuse  perspiration  with  heat  of  skin,  in  the  Jits  of  spasm  especially. — 
In  the  fits  of  spasm  the  skin  becomes  hot  and  literally  drenched  in 
perspiration,  and  in  a  lesser  degree  this  state  of  things  continues  in 
the  intervals  between  these  fits,  except  towards  the  end,  when  the  chill 
damps  of  death  show  themselves.  Sometimes  the  perspiration  has  a 
peculiar  pungent  smell,  sometimes  it  is  accompanied  by  a  miliary 
eruption.  The  degree  of  heat  attained  is  often  considerable — in  some 
cases  as  high  even  as  105°  and  110.75°  Fahr. 

Absence  of  fever.  — The  heat  of  skin  which  has  just  been  mentioned 
may  at  first  sight  appear  to  countenance  the  notion  that  fever  is  a  part 
of  tetanus,  but  it  is  evident  on  further  inquiry  that  this  phenomenon 
is  mostly  connected,  not  with  fever,  but  with  dyspnoea,  the  skin  receiv- 
ing more  blood,  and  in  that  way  acquiring  increased  temperature  in 
obedience  to  that  law  of  compensation  by  which  to  a  certain  degree 
the  skin  is  obliged  to  do  more  respiratory  work  when  the  lungs  do 
less  than  they  ought  to  do.  The  thirst,  also,  which  is  often  so  much 
complained  of  when  the  disease  is  at  its  height,  is  owing  less  to  fever 
than  to  the  inability  to  drink  the  fluids  necessary  to  the  wants  of  the 
system,  for  the  patient  is  often  hungry  at  the  very  time  he  is  tortured 
with  thirst — a  plain  proof  that  he  has  no  fever  in  the  true  sense  of  the 
word.  Nor  does  the  pulse  support  the  idea  of  fever.  On  the  contrary, 
the  pulse  points  to  exhaustion  rather  than  to  fever,  being  scarcely 
ever  otherwise  than  quick  and  weak ;  and  if  in  the  fits  of  spasm  it 
puts  on  a  semblance  of  power,  it  is  plain,  from  the  state  of  suffocation 
obtaining  at  the  time,  that  this  change  is  simply  owing,  as  I  have  else- 
where explained,  to  the  difficult  passage  of  imperfectly  aerated  blood 
through  the  capillaries.  In  fact,  in  the  great  majority  of  cases  of 
tetanus  there  is  no  fever,  and  in  the  exceptional  cases  where  some  fever 
is  present,  its  history  shows  that  it  is  a  consequence  rather  than  a  cause 
of  the  spasm,  seeing  that  it  is  absent  at  first,  and  present  only  when 
the  system  is  becoming  exhausted  by  starvation,  sleeplessness,  and 
spasm. 

Absence  of  sleep. — In  the  acute  cases  sleep,  as  a  rule,  is  banished 
altogether,  and  even  in  the  subacute  cases  this  blessing  is  only  realized 
4 


50  DISEASES    OF    THE    SPINAL    CORD. 

in  unrefreshing  broken  snatches.  Want  of  sleep,  indeed,  is  one  of  the 
not  least  distressing  features  of  this  disease.  "The  muscles,"  says  Mr. 
Curling,  "  are  observed  to  be  relaxed  during  sleep,  a  striking  example 
of  which  occurred  to  Mr.  Mayo  in  a  boy  who  recovered  from  the  disease. 
On  visiting  his  patient  before  the  symptoms  were  subdued,  Mr.  Mayo 
found  him  asleep,  and  remarked  that  he  lay  perfectly  relaxed.  The 
abdominal  muscles  were  soft  and  yielding,  and  had  not  the  least 
tension.  The  boy  was  awakened,  and  at  the  instant  the  full  tension, 
of  the  muscles  returned.  Not  being  further  disturbed,  he  fell  asleep 
in  a  few  minutes,  when  the  muscles  again  became  relaxed,  and  again, 
on  his  being  awakened,  resumed  the  state  of  spasm.  I  have  on  several 
occasions  witnessed  the  same  phenomena."  Except  the  biting  of  the 
tongue,  on  waking  from  a  brief  nap,  be  a  reason  for  believing  that  the 
muscles  of  the  jaws  had  been  relaxed  during  sleep,  so  as  to  allow  the 
tongue  to  get  between  the  teeth,  there  was  no  proof  that  the  muscles 
were  relaxed  during  sleep  in  the  case  I  have  given ;  but  in  other  cases 
I  have  had  proof  sufficient  of  this  relaxation. 

Absence  of  numbness  and  tingling. — Of  this  there  can  be  no  doubt — 
that  numbness  and  tingling  form  no  part  of  the  history  of  tetanus. 

Absence  of  "head  symptoms}'1 — The  mind  is  clear  from  the  beginning 
to  the  end  of  the  disease  almost  invariably,  and  not  unfrequently  it  is 
a  matter  for  wonder  how  well  the  patient  bears  up  under  his  atrocious 
sufferings — a  marked  difference  this  between  tetanus  and  hydrophobia. 
And  in  the  few  instances  in  which  delirium  or  coma  has  made  its 
appearance  a  short  time  before  death,  it  is  not  improbable,  as  more 
than  one  writer  has  observed,  that  this  derangement  is  often  more  the 
result  of  the  remedies  employed  than  of  the  disease. 

No  marked  want  of  control  over  the  bladder  or  bowel. — In  tetanus  there 
is,  as  a  rule,  none  of  the  difficulty  with  the  bladder  which  is  almost 
invariably  met  with  in  acute  spinal  meningitis.  The  bladder  may  act 
seldom,  but  it  is  not  incapable  of  acting.  Constipation  is  a  common 
but  not  a  constant  symptom,  and  when  it  is  present  it  may  be  a  ques- 
tion whether,  like  the  "head-symptoms,"  it  is  not  as  much  due  to  the 
medicines  used  as  to  the  disease.  Now  and  then,  however,  there  may 
be  great  difficulty  in  voiding  the  contents  of  the  bladder  and  bowels, 
and  in  some  of  these  cases  the  resistance  to  the  introduction  of  a 
catheter  or  enema-pipe  lias  shown  that  a  part  of  this  difficulty  is  owing 
to  spasm  of  the  compressor  urethras  or  sphincter  ani. 

Comparative  voicelessness. — This  phenomenon  is  readily  accounted 
for  as  a  result  of  the  spasmodic  interference  with  the  action  of  the 
chest  and  of  the  tight  shutting  of  the  jaws.  Indeed,  it  could  not  well 
be  otherwise  in  the  fully  developed  disease. 

The  mouth  clogged  with  viscid  frothy  saliva. — This  is  a  common  if  not 
a  constant  symptom,  though  not  so  marked  in  degree  as  in  hydro- 
phobia, and  there  is  no  difficulty  in  accounting  for  it  in  either  case,  for 
the  inability  to  drink  and  swallow  will  explain  at  one  and  the  same 
time  why  the  saliva  is  viscid  and  why  it  accumulates  in  the  mouth. 

A  bitten  tongue  or  cheek. — This  accident  is  of  rare  occurrence,  and  its 
rarity  may  be  taken  as  an  incidental  proof  of  sleeplessness  as  a  symptom 
of  tetanus,  for  it  is  to  be  supposed  that  the  opening  of  the  jaws,  from 


TETANUS.  51 

c  r   /  ' (/  G  r 

the  relaxation  of  their  muscles  during  sleep,  would  allow  the  tongue  or 
cheek  to  get  between  the  teeth — to'get  into  that  position  in  wh&h  the^ 
spasm  which  attends  the  moment  of  waking  would  be  sure  to  crush 
them. 

Dilatation  of  pupil. — This  condition  was  always  present  in  the  case 
which  serves  as  my  text,  especially  in  the  fits  of  spasm,  and  this  has 
been  the  rule  in  three  cases  of  tetanus  in  which  I  have  examined  the 
pupil.  Mr.  Curling,  on  the  contrary,  found  the  pupil  contracted  in 
the  majority  of  his  cases. 

Absence  of  priapism. — Mr.  Morgan  states  that  priapism  occurs  occa- 
sionally ;  but  this  observation  is  not  confirmed  by  other  writers  on  the 
subject.  I  have  never  seen  it,  and  I  am  very  much  disposed  to  think 
that  the  case  or  cases  in  which  Mr.  Morgan  saw  it  were  cases,  not  of 
tetanus,  but  of  acute  spinal  meningitis,  in  which  disorder  priapism  is 
an  occasional  symptom. 

Presence  of  a  wound. — The  great  majority  of  cases  of  acute  tetanus 
appear  to  be  in  some  way  dependent  upon  a  wound  or  injury  of  one 
kind  or  another  in  one  place  or  another.  I  shall  have  occasion  to 
refer  to  this  relationship  elsewhere:  and  at  present  I  would  only 
notice,  in  passing,  the  presence  of  a  wound  which  to  all  appearance 
presented  no  indications  of  an  inflammatory  or  otherwise  unhealthy 
character. 

Death  by  apnoea. — Apncea  is  one  way,  and  perhaps  the  common 
way,  in  which  death  is  brought  about  in  tetanus.  Not  unfrequently, 
however,  the  patient  sinks  from  asthenia,  having  been  to  a  great 
degree  free  from  fits  of  suffocative  spasm  for  some  time  before  death. 
Spasm  of  the  heart  has  also  been  mentioned  as  a  method  of  dying  in 
tetanus,  and  the  heart  has  not  unfrequently  been  found  to  be  curiously 
hard  and  contracted  after  death;  but  an  examination  of  the  facts  tends 
very  much  to  discountenance  this  idea,  and  to  show  that  death  is  either 
by  apnoea  or  asthenia,  singly  or  together. 

The  immediate  occurrence  of  rigor  mortis. — Sommer  and  others  have 
noticed  that  rigor  mortis  may  occur  without  any  appreciable  interval 
of  muscular  relaxation  after  death  from  convulsions,  and  Dr.  Brown- 
Sequard  has  confirmed  this  observation  and  given  a  definiteness  to  it 
which  it  had  not  before.  He  has  indeed  done  more  than  this,  for  he 
has  not  only  confirmed  the  fact  that  rigor  mortis  may  occur  without 
any  appreciable  interval  of  muscular  relaxation,  but  he  has  established 
the  law  that  rigor  mortis  is  long  in  coming  on  and  long  in  passing  off 
where  death  was  not  preceded  by  any  long-continued  violent  action 
of  the  muscles,  and  that  it  is  quick  in  coming  on  and  quick  in  passing 
off  in  direct  proportion  to  the  amount  of  long-continued  violent  action 
which  preceded  death.  In  many  animals  killed  by  strychnine,  for 
example,  in  which  death  was  brought  about,  not  by  one  violent 
spasm,  but  by  many,  he  has  found  rigor  mortis  set  up  before  the  heart 
had  ceased  to  beat.  Nay,  he  even  refers  to  the  case  of  a  man  under 
his  observation  in  which  rigor  mortis  occurred  before  the  heart  had 
ceased  to  beat.  I  have  never  witnessed  this  phenomenon  either  in 
animals  or  in  man  ;  but  I  have  more  than  once  failed  to  find  any  line 
of  separation  between  tetanic  stiffness  and  cadaveric  rigidity  in  ani- 


52  DISEASES    OF   THE    SPINAL    CORD. 

mals  killed  by  strychnine,  or  by  the  shocks  of  a  Ruhmkorff  coil ;  and 

I  am  therefore  quite  prepared  to  understand  that  in  P.  M 's  case, 

where  J-here  were  many  convulsions  before  death,  rigor  mortis  may 
have  occurred^  without  any  appreciable  interval  of  muscular  relaxation, 
and  in  this  way  fixed  in  the  corpse  the  aged  expression  of  the  counte- 
nance, and  the  opisthotonic  attitude. 

Two  distinct  varieties  of  tetanus  are  usually  recognized,  and  properly 
so — the  traumatic,  in  which  a  hurt  of  some  kind  or  other  is  believed 
to  be  the  primary  cause;  and  the  idiopathic, in  which  the  only  obvious 
cause  would  seem  to  be  exposure  to  cold  and  damp.  In  each  variety 
the  symptoms  are  much  the  same,  any  difference  of  moment  being 
only  one  of  degree.  In  the  acute  form,  the  spasms  come  on  suddenly, 
occur  frequently,  and  grow  in  violence  with  each  recurrence ;  in  the 
less  acute  forms  the  spasms  are  more  slowly  developed  in  the  first  in- 
stance, the  paroxysms  are  comparatively  far  between,  and  they  do  not 
recur  with  increasimg  rapidity  and  violence.  The  traumatic,  as  a  rule, 
is  more  acute  than  the  idiopathic  variety.  Trismus  nascentium  is 
considered  by  many  as  a  distinct  variety  of  tetanus,  but  this  appears 
to  be  a  distinction  without  a  real  difference.  It  is  tetanus  in  newly- 
born  infants — traumatic,  because  the  wound  of  the  navel  seems  to 
have  a  good  deal  to  do  with  its  production,  and  at  the  same  time  idio- 
pathic, for  it  is  certain  that  cold  and  damp,  and  foul  air,  and  other 
general  causes  also  figure  conspicuously  as  sources.  It  is,  indeed  to 
this  form  of  tetanus  that  a  remark  of  Sir  Thomas  Watson  applies 
especially,  which  is  applicable  to  all  forms,  namely,  this,  that  "  although 
tetanus  may  be  excited  by  a  wound,  independently  from  exposure  to 
cold,  or  by  cold,  without  any  bodily  injury,  there  is  good  reason  for 
thinking  that,  in  many  instances,  one  of  these  causes  alone  would  fail 
to  produce  it,  while  both  together  call  it  forth." 

2.  POST  MORTEM  APPEARANCES. — There  are  no  morbid  changes  in 
the  nervous  system  peculiar  to  tetanus.  "  Serous  effusion  with  in- 
creased vascularity,"  says  Mr.  Curling,  "is  generally  observed  in  the 
membranes  investing  the  medulla  spinalis,  and  also  a  turgid  state  of 
the  bloodvessels  about  the  origin  of  the  nerves,"  and  the  same  changes 
may  also  be  met  with  in  the  cranium,  but  in  a  less  degree  and  less 
frequently.  It  is  also  a  fact  of  considerable  moment  in  relation  to  this 
point,  that  Magendie,  Ollivier,  and  Orfila  failed  to  detect  any  perceptible 
lesion  in  the  spinal  cords  of  animals  dying  from  the  tetanus  produced 
by  strychnia.  Out  of  seventy  fatal  cases  collected  by  Mr.  Curling 
there  were  only  two  in  which  changes  in  the  nervous  system  unequi- 
vocally the  result  of  inflammatory  action  were  discovered  after  death, 
and  these  two  were  cases  where  there  had  been  a  blow  or  wound  to  the 
back,  where  the  symptoms  had  plainly  to  do  with  the  inflammation 
of  the  cord  or  its  membranes  rather  than  with  tetanus,  and  where  the 
signs  of  inflammation  found  after  death  may,  to  say  the  least,  be  referred 
to  the  injury  quite  as  easily  as  to  the  tetanus.  Mr.  Curling  also  points 
out,  as  a  fact  not  to  be  overlooked,  that  the  turgid  state  of  the  vessels 
of  the  pia  mater,  together  with  the  effusion  of  serum  which  is  met 


TETANUS.  53 

j,vith  in  the  spinal  cord  and  brain  after  death  from  tetanus,  is  also  met 
in  those  persons  who  have  been  poisoned  by  opium,  hydrocyanic  acid, 
and  other  powerful  agents  often  employed  in  the  treatment  of  tetanus, 
as  well  as  after  death  from  delirium  tremens,  hydrophobia,  epilepsy, 
and  other  diseases ;  and,  as  bearing  upon  these  exceptional  cases,  in 
which  unequivocal  signs  of  inflammation  in  the  cord  or  brain  have 
been  met  with  after  death  from  tetanus,  he  says,  "  Whether  inflam- 
mation be  the  result  of  injury  or  arises  spontaneously,  it  is  worthy  of 
notice  that  the  spasms,  though  continued  and  severe,  do  not  occur  in 
such  violent  paroxysms  as  in  traumatic  tetanus."  Neither  can  the 
preternaturally  injected  state  of  the  minute  vessels  supplying  the 
sympathetic  ganglia,  especially  the  cervical  and  semilunar,  met  with 
by  Mr.  Swan  and  others  in  some  cases  of  tetanus,  be  looked  upon  as  at 
all  constant  phenomena  after  death  from  tetanus. 

Traces  of  inflammation  in  the  wound,  especially  in  the  injured 
nerves,  may  be  met  with  after  death  from  tetanus,  and  more  frequently 
than  in  the  spinal  cord  or  other  great  nervous  centres;  but  these 
again,  instead  of  being  constant,  are  not  even  common  appearances. 
In  the  great  majority  of  cases,  indeed,  the  wound,  if  there  be  one,  is 
perfectly  healthy  to  all  appearance  and  healing.  Neither  are  there  any 
other  post-mortem  facts  which  can  be  looked  upon  as  essential  to 
tetanus,  for  those  which  remain  to  be  mentioned,  as  ruptured  muscles, 
broken  or  dislocated  bones,  engorged  lungs,  injection  and  contraction 
of  the  pharynx  and  palate,  worms  in  the  alimentary  canal,  and  others, 
are  plainly  accidental  and  exceptional. 

3.  CAUSES. — The  two  great  causes  of  tetanus  are,  as  has  been 
mentioned  already,  cold  and  damp,  and  bodily  injury  of  some  sort. 
Exposure  to  cold  and  damp  tells  most  in  this  manner  when  acting 
upon  a  body  previously  relaxed  by  heat  and  perspfring,  and  this  is  all 
that  can  be  said,  except  that  this  exposure  is  more  likely  to  issue  in 
tetanus  in  a  foul  atmosphere  than  in  a  fresh  one.  As  regards  the 
hurt  which  may  give  rise  to  tetanus,  it  is  difficult  to  know  what  to  say. 
In  the  Peninsular  war,  as  Sir  James  McGregor  states,  tetanus  super- 
vened on  every  description  and  in  every  stage  of  the  wounds,  from  the 
slightest  to  the  most  formidable,  in  the  healthy  and  sloughing,  the 
incised  and  lacerated,  the  most  simple  and  the  most  complicated ;  and 
this  statement  expresses  the  opinion  of  all  surgeons,  army-surgeons 
and  others.  Indeed,  all  that  can  be  said  is  that  punctured  wounds 
seem  to  be  more  likely  to  issue  in  tetanus  than  incised,  and  wounds  in 
the  extremities  more  than  wounds  in  the  head,  breast,  and  neck. 
And  certainly  an  inflammatory  condition  of  the  wound  cannot  be  re- 
garded as  essential.  In  a  great  number  of  cases,  in  the  majority 
perhaps,  the  primary  wound  was  completely  healed  and  almost  for- 
gotten when  the  symptoms  of  tetanus  made  their  appearance;  and 
Dr.  Eush,  who  had  extensive  opportunities  for  observation  in  the 
military  hospitals  of  the  United  States,  and  who  was  unquestionably  a 
most  competent  observer,  remarks  that  there  was  invariably  an  absence 
of  inflammation  in  the  wounds  causing  the  disease.  John  Hunter 
also  says:  "The  wounds  producing  tetanus  are  either  considerable  or 


54  DISEASES    OF    THE    SPINAL    COED. 

slight.  .  .  .  When  I  have  seen  it  from  the  first,  it  was  after  the  in-, 
flarnmatory  stage,  and  when  good  suppuration  was  come  on;  in  some 
cases  when  it  had  nearly  healed,  and  the  patient  was  considered 
healthy.  Some  have  had  locked  jaw  after  the  healing  was  completed. 
In  such  I  have  supposed  the  inflammation  to  be  the  predisponent 
cause,  rendering  the  nervous  system  irritable  as  soon  as  it  was 
removed.  When  tetanus  comes  on  in  horses,  as  after  docking,  it  is 
after  the  wound  has  suppurated  and  begun  to  heal."  There  is,  indeed, 
abundant  evidence  to  show  that  an  inflammatory  condition  of  the 
wound  is  not  necessary  to  the  production  of  tetanus,  and  some 
evidence  even  which  is  calculated  to  lead  to  a  contrary  conclusion,  by 
showing  that  where  an  inflammatory  condition  of  the  wound  has  been 
present,  this  condition  has  passed  off  before  the  tetanic  symptoms  made 
their  appearance — the  inflammation,  to  repeat  the  words  of  John 
Hunter  just  used,  "rendering  the  nervous  system  irritable  as  soon  as 
it  was  removed"  not  rendering  it  irritable  as  long  as  it  was  present. 
The  interval  between  the  hurt  and  the  development  of  the  tetanic 
symptoms  varies  considerably.  In  eighty-one  of  the  cases  collected 
by  Mr.  Curling,  the  symptoms  made  their  appearance  between  the 
fourth  and  fourteenth  days,  both  inclusive,  and  in  nineteen  on  the 
tenth  day.  Four  cases  are  also  given  in  which  the  symptoms  came 
on  more  speedily,  one  (somewhat  doubtful)  almost  instantaneously, 
another  in  one  hour,  a  third  in  two  hours,  and  the  fourth  in  eleven 
hours,  and,  at  the  other  extreme,  one  in  which  they  were  deferred  as 
late  as  the  tenth  week.  In  traumatic  tetanus  the  sooner  the  symptoms 
show  themselves  the  more  acute  and  dangerous  is  the  malady.  In 
idiopathic  tetanus  the  symptoms,  as  a  rule,  commence  sooner  than  in 
traumatic  tetanus,  often  in  a  few  hours;  but  the  idiopathic  notwith- 
standing, is  generally  of  a  more  chronic  kind  than  the  traumatic,  and 
far  less  dangerous.  * 

Tetanus  is  not  a  malady  peculiar  to  any  country,  or  climate,  or 
people,  but  it  is  more  common  in  hot  countries  than  in  cold.  It  would 
appear,  also,  that  negroes  are  more  likely  to  be  attacked  than  whites. 
Great  atmospheric  changes,  especially  from  heat  to  cold  and  damp,  as 
to  a  cold  and  dewy  night  after  a  sultry  day,  are  evidently  most  favor- 
able to  the  development  of  tetanus,  and  so  in  a  less  degree  are  foul  air, 
despondency,  terror,  physical  exhaustion.  It  must  be  confessed,  how- 
ever, that  cases  of  idiopathic  tetanus,  as  compared  with  those  which 
are  traumatic,  or  partly  idiopathic  and  partly  traumatic,  are,  to  say 
the  least,  extremely  rare  in  this  country. 

4.  DIAGNOSIS. — The  differences  between  tetanus  and  acute  spinal 
meningitis  are  sufficiently  marked  to  prevent  any  confusion  as  to 
diagnosis  if  only  a  moderate  degree  of  attention  be  paid  to  the  subject. 
In  tetanus  the  jaw  is  firmly  set  from  the  first,  and,  in  addition  to  the 
fits  of  spasm,  there  is  permanent  muscular  rigidity  between  the  fits ; 
in  spinal  meningitis,  if  the  jaw  be  set  at  all,  it  is  rather  at  the  close  of 
the  disease,  and  then  only  in  an  inconsiderable  degree,  and  spasms  or 
muscular  rigidity  are  neither  constant  nor  conspicuous  phenomena. 
In  spinal  meningitis,  indeed,  it  is  plain  that  the  muscular  rigidity  and 


TETANUS.  55 

geeming  spasms  are  in  great  measure  voluntary  or  semi-voluntary  acts 
to  prevent  the  pain  in  the  back  and  limbs  which  is  produced  by  move- 
ment, and  that  the  muscles  are  relaxed  almost  as  long  as  the  patient 
can  keep  perfectly  still.  In  a  word,  the  true  involuntary  fits  of  spasm 
and  the  permanent  muscular  rigidity  which  are  constant  and  character- 
istic phenomena  in  tetanus,  are  not  present  in  acute  spinal  menin- 
gitis. 

Nor  can  hydrophobia  be  very  well  confounded  with  tetanus.  In 
tetanus  the  features  are  drawn  into  the  risus  sardonicus,  the  eyes  are 
natural,  and  the  whole  countenance  is  expressive  of  pain  and  suffering 
— nothing  more ;  in  hydrophobia  there  is  an  impress  of  excitement  and 
distress  and  horror  and  unrest  upon  the  features  which  has  no  counter- 
part in  the  tetanic  countenance.  In  tetanus  the  body  is  for  the  most 
part  rigidly  fixed  in  one  position  by  tonic  spasm ;  in  hydrophobia  the 
spasmodic  movements  are  clonic,  and  the  body  is  in  a  state  of  per- 
petual unrest  until  the  stage  of  final  exhaustion.  In  hydrophobia, 
noisy  attempts  are  continually  made  to  spit  and  hawk  away  the  viscid 
phlegm  which  fills  the  mouth  and  throat  to  overflowing — the  noises 
being  sometimes  not  altogether  unlike  the  bark  of  a  dog — and  any 
effort  to  relieve  the  tormenting  thirst,  or  even  the  bare  thought  of  such 
an  effort,  brings  on  the  fit  of  fear  and  convulsive  agitation  which  has 
given  rise  to  the  name  hydrophobia  :  in  tetanus  there  are  no  symptoms 
which  can  be  considered  as  strictly  comparable  to  these.  In  tetanus, 
finally,  the  mind  is  clear  to  the  last,  whereas  in  hydrophobia  there  is 
almost  from  the  first  a  peculiar  and  often  very  wild  delirium. 

The  tetanic  symptoms  produced  by  strychnia  and  some  other  poisons 
may  be  more  easily  confounded  with  traumatic  tetanus,  but  even  here 
it  is  possible,  with  care,  to  make  a  correct  diagnosis.  It  is  possible,  as 
Dr.  Christison  pointed  out,  for  strychnia  to  be  given  in  repeated  doses 
so  regulated  as  to  produce  a  train  of  symptoms  scarcely  if  at  all  dis- 
tinguishable from  traumatic  tetanus ;  but  not  so  if,  as  is  usually  the 
case,  an  amount  sufficient  to  produce  death  be  given  in  one  dose.  In 
this  latter  case,  indeed,  the  differences  of  the  symptoms  are  sufficiently 
marked.  In  the  toxic  tetanus  the  symptoms  run  a  rapidly  fatal  course, 
death  happening  in  a  quarter  of  an  hour,  half  an  hour,  and  usually 
within  the  hour:  in  traumatic  tetanus,  with  very  few  exceptions,  life 
when  briefest  is  prolonged  for  two  or  three  days.  In  the  toxic  tetanus 
the  arms  are  stretched  stiffly  out,  the  hands  clenched,  and  the  legs 
separated  widely  from  each  other  and  rigidly  extended :  in  traumatic 
tetanus  the  hands  are  usually  free  from  spasm,  and  the  arms  nearly  so, 
and  even  the  legs  are  scarcely  ever  affected  to  the  degree  which  is  seen 
in  toxic  tetanus.  In  the  tetanus  caused  by  strychnia,  Mr.  Poland 
says,  "  The  patient  can  open  his  mouth  to  swallow ;  there  is  no  locked 
jaw:"  in  traumatic  tetanus,  locked  jaw  is  the  first  and  most  constant 
manifestation  of  the  spasm. 

The  jaw  may  be  locked  for  a  long  time,  and  various  muscles  in  other 
parts  may  be  affected  with  continuous  spasm  in  cases  in  which  hysteria 
is  supposed  to  figure  largely  as  a  cause — cases  in  which  there  is  the 
condition  called  spinal  irritation,  about  which  I  have  to  treat  in  the  next 
article :  but  these  cases,  as  will  appear  in  due  time,  even  when  most 


56  DISEASES    OF    THE    SPINAL    COED. 

like,  are  in  reality  so  unlike  tetanus  as  scarcely  to  deserve  even  this 
passing  mention. 

5.  PROGNOSIS. — In  the  cases  "  in  which  the  access  is  slow,  the  spasms 
by  no  means  violent,  the  paroxysms  slight  and  recurring  at  long  in- 
tervals, and  where  the  patient  can  obtain  sleep,  whether  traumatic  or 
not,  we  may  generally  anticipate  a  favourable  result ;"  and  again,  "  the 
longer  the  interval  before  the  appearance  of  the  symptoms,  the  more 
chronic  is  the  disease,  and  the  greater  the  probability  of  recovery." 
So  speaks  Mr.  Curling  of  the  chronic  cases  of  tetanus  in  contradistinc- 
tion to  the  acute ;  and  in  illustration  of  the  probability  of  recovery,  he 
adds:  "In  thirteen  cases,  symptoms  of  tetanus  occurred  about  three 
weeks  after  the  wound,  and  four  only  were  fatal ;  and  of  seven  cases 
in  which  they  did  not  make  their  appearance  till  after  a  month,  only 
two  ended  fatally."     In  the  cases,  on  the  other  hand,  in  which  the 
spasms  supervene  rapidly  upon  the  injury,  and  recur  with  increasing 
violence  at  decreasing  intervals,  and  in  which  sleep  is  banished,  a  vast 
majority  die — die,  as  Hippocrates  noticed  ages  ago,  within  four  days. 
Death  may  happen  in  a  fit  of  suffocation  in  which  sometimes  there  is 
obviously  spasm  of  the  glottis,  but  more  frequently  it  would  seem  to  be 
brought  about  by  asthenia  after  a  fit  of  spasm.     The  time  occupied  in 
recovery  varies  greatly — one,  two,  three,  four,  five,  six,  seven,  eight 
weeks,  or  even  longer.     A  certain  degree  of  weakness  and  stiffness  may 
also  remain  in  the  muscles  long  after  recovery.     In  one  case  rigidity 
of  the  muscles  of  the  jaw  remained  for  six  months;  in  another  it  re- 
turned whenever  the  patient  caught  cold  up  to  nine  months;  and  in  a 
third,  at  the  end  of  three  years,  it  is  stated  that  the  "  features  retained 
the  indelible  impression  of  the  disease."     These  cases  are  given  by 
Mr.  Curling. 

6.  TREATMENT. — After  passing  in  review  the  principal  remedies  that 
have  been  tried  in  tetanus — opium,  bloodletting,  the  cold  bath  and 
cold  affusion,  ice  to  the  spine,  the  warm  bath,  bark,  wine  and  spirits, 
mercury,  purgatives,  foxglove,  tobacco,  musk,  prussic  acid,  carbonate 
of  iron,  oil  of  turpentine,  strychnia,  woorali,  ether  and  chloroform 
inhalations,  amputation,  division  of  nerves,  tourniquets — Sir  Thomas 
Watson  says :  "  In  all  cases,  there  being  no  special  indication  to  the 
contrary,  I  should  be  more  disposed  to  administer  wine  in  large  quan- 
tities, and  nutriment,  than  any  particular  drug;"  and  this  statement, 
I  take  it,  expresses  a  very  general  feeling  in  this  country.     For  my 
own  part,  I  should  certainly  be  more  disposed  to  trust  to  alcohol  than 
to  any  drug;  but,  in  saying  this,  I  do  not  say  that  I  should  place  no 
confidence  in  drugs.     I  should  certainly  place  no  confidence  in  any 
sedative  or  narcotic  given  by  the  stomach  in  sedative  or  narcotic  doses ; 
but,  on  empirical  as  well  as  on  theoretical  grounds,  I  should  say  that 
opium  can  scarcely  be  dispensed  with,  and  that  chloroform  or  ether 
inhalations  will  be  of  infinite  service  in  relieving  pain  and  spasm,  and 
that  too  without  compromising  the  chances  of  recovery,  if  care  be 
taken  to  pour  in  wine  and  to  supply  nourishment  at  the  same  time  so 
as  to  prevent  the  patient  from  waking  up  almost  immediately  after  the 
inhalation. 


TETANUS.  57 

If  the  rationale  of  spasm  be  that  which  is  hiuted  at  in  the  prelimi- 
nary remarks,  the  great  indication  of  treatment  must  be,  not  to  depress 
the  circulation,  but  to  rouse  it  into  greater  activity ;  and  one  reason 
why  the  treatment  of  tetanus  has  been  so  eminently  unsatisfactory  may 
be  that  this  indication  has  not  been  fully  realized  and  carried  out.  la 
tetanus  much  wine  may  be  given  without  producing  anything  like  in- 
toxication, or  without  relaxing  the  spusms  in  any  degree.  The  system 
in  this  disease  is  altogether  insensible  to  the  action  of  wine  in  ordinary 
doses.  As  to  this  there  can  be  no  doubt.  Whether  a  different  result 
would  have  been  arrived  at  if  alcohol  had  been  given  more  boldly, 
ardent  spirits  in  place  of  wine,  ardent  spirits  undiluted  rather  than 
diluted,  is  yet  an  open  question,  but  I  am  disposed  to  think  that  the 
spasms  might  have  been  conquered  without  compromising  the  safety 
of  the  patient  if  this  had  been  done.  There  are  now  not  a  few  cases 
on  record  which  show  that  the  bite  of  a  rattlesnake  or  cobra  or  other 
deadly  serpent  may  be  prevented  from  killing  by  at  once  giving  ardent 
spirits  in  sufficient  quantity,  and  I  am  disposed  to  think  that  these 
facts  have  an  important  bearing  upon  the  treatment  of  tetanus.  There 
are,  undoubtedly,  great  differences  between  the  condition  in  tetanus 
and  the  condition  in  these  poisoned  bites,  but  there  are  also  certain 
resemblances  which  must  not  be  lost  sight  of.  There  is  the  same 
insensibility  to  the  action  of  alcohol  in  ordinary  doses ;  there  is  an 
exhaustion  to  be  counteracted,  which  is  more  rapidly  fatal  in  the 
poisoned  bite  than  in  tetanus,  but  which  in  acute  tetanus  is  sufficiently 
rapid  to  create  the  gravest  fears,  and  to  justify  the  most  heroic  mea- 
sures ;  there  may  be  a  poison  at  work  in  both  cases  as  well  as  a  wound, 
a  poison  introduced  into  the  wound  in  one  case,  a  poison  generated 
in  the  wound  in  the  other  case.  There  are  resemblances  between  the 
two  cases,  indeed,  which,  though  not  very  close,  may  be  close  enough 
to  justify  the  hope  that  a  practice  which  has  been  found  to  answer  in 
the  bite  of  a  poisonous  serpent  may  also  be  found  to  answer  in  acute 
tetanus. 

In  speaking  thus,  it  is  not  intended  to  imply  that  ardent  spirits  are 
the  only  way  of  fulfilling  what  has  been  said  to  be  the  primary  in- 
dication of  treatment  in  tetanus.  Bau  de  luce  has  been  found  to  be 
of  great  service  in  the  bites  of  serpents,  and  it  might  be  of  service  in 
tetanus.  Ether,  also,  might  be  of  use,  or  turpentine,  or  camphor,  or 
ammonia.  But  to  my  mind  these  and  other  medicines  of  a  like  nature 
are  more  likely  to  disorder  the  stomach  and  system  generally,  and  in 
other  respects  are  less  manageable  and  less  certain  in  their  action  than 
ardent  spirits,  and  for  these  reasons  without  any  just  claims  to  prece- 
dence in  order  of  merit. 

As  regards  local  measures  it  is  less  difficult  to  arrive  at  a  conclusion. 
In  many  cases,  no  doubt,  there  is  an  eccentric  irritation,  starting  from 
the  wound  or  some  other  point,  and  much  good  would  be  done  if  this 
could  be  'removed.  It  is  probable,  also,  that  this  end  might  be  gained 
in  more  ways  than  one,  and  that  one  very  direct  way  is  by  the  sub- 
cutaneous injection  of  various  substances — morphia,  atropine,  woorali, 
conia  (which  seems  to  be  strictly  analogous  in  its  action  to  woorali), 
calabar  bean,  £c.  The  results  of  these  injections  in  causing  the  relaxa- 


58  DISEASES    OF   THE    SPINAL    CORD. 

tion  of  spasm  in  connection  with  the  minor  forms  of  spinal  irritation 
are  very  encouraging.  One  thing,  however,  ought  to  be  borne  in 
mind,  and  that  is,  that  these  injections  should  be  used  so  as  not  to 
produce  a  general  depressing  or  paralyzing  effect  upon  the  nervous 
system.  All  that  ought  to  be  aimed  at  is  to  obviate  local  irritation 
merely;  and,  to  my  mind,  to  go  beyond  this  point  is  both  wrong  in 
principle  and  dangerous  in  practice. 

For  the  rest,  it  is,  of  course,  desirable  that  the  patient  should  be 
carefully  guarded  from  cold,  and  from  anything  which  would  excite 
or  disturb  him,  as  too  much  light  or  noise,  or  too  meddlesome  nursing. 
In  a  word,  quiet  and  warmth  are  not  only  desirable :  they  are  indis- 
pensable. 

V.  IRRITATION. 

The  first  important  work  on  the  disorder  now  generally  known  as 
spinal  irritation  was  published  by  Mr.  Teale,  of  Leeds,  nearly  forty 
years  ago;1  the  next  by  the  brothers  Dr.  and  Mr.  Griffin,  of  Limerick, 
about  fifteen  years  later.2  To  Mr.  Teale,  indeed,  belongs  the  credit  of 
being  the  first  to  direct  attention  to  this  disorder,  for,  in  reality,  his 
claim  either  to  priority  or  originality  is  scarcely,  if  at  all,  invalidated 
by  the  short  communications  which  were  made  previously  to  medical 
periodical  literature  by  Mr.  Player,  of  Malmsbury,3  by  Dr.  Brown,  of 
Glasgow,4  by  Dr.  Darwell,  of  Birmingham,5  and  still  less  so  by  any- 
thing written  about  the  commencement  of  the  century  by  Franks, 
Nicod,  Ludwig,  and  others.  It  would  also  seem  to  be  difficult  to  find 
any  work  of  more  recent  date  which  deserves  to  be  mentioned  as  at  all 
equal  in  merit  and  importance  to  that  of  the  brothers  Griffin.  The 
name  "  spinal  irritation"  was  first  proposed  by  Dr.  Brown,  of  Glas- 
gow. 

1.  SYMPTOMS. — The  symptoms  of  spinal  irritation  at  first  sight 
appear  to  be  as  vague  and  various  as  those  of  hysteria.  They  are  in 
reality  so  far  hysterical  as  to  be  not  readily  distinguishable.  When 
further  examined,  however,  one  symptom  stands  out  prominently, 
with  which  the  others  are  obviously  connected  in  a  peculiar  manner ; 
namely,  spinal  tenderness,  and  the  upshot  of  the  whole  matter  appears 
to  be  that  spinal  irritation  is  a  definite  malady  which  must  not  be  con- 
founded with  hysteria  or  with  any  other  disorder.  The  case  I  take 
as  a  text  is  as  follows : — 

Case. — An  unmarried  lady,  aged  twenty-three,  who  consulted  me  in 
the  early  part  of  1863  for  pains  in  the  head  and  face,  loss  of  appetite, 
nausea,  flatulence,  palpitation,  breathlessness,  "  sinking  feelings,"  weak- 

1  A  Treatise  on  Neuralgic  Diseases  dependent  upon  Irritation  of  the  Spinal  Marrow 
and  Ganglia  of  the  Sympathetic  Nerve.    By  T.  P.  Teale.    8vo.   London  :  Highley,  1829. 

2  Observations  on  the  Functional  Affections  of  the  Spinal  Cord  and  Ganglionic  System 
of  Nerves,  in  which  their  Identity  with  Sympathetic,  Nervous,  and  Irritative  Diseases 
is  illustrated.     By  William  Griffin,  M.D.  and  David  Griffin.     8vo.     London  :  Burgess 
and  Hill.     1844. 

3  Quarterly  Journal  of  Science,  January,  1822. 

4  Glasgow  Medical  Journal,  May,  1828. 

6  Midland  Medical  and  Surgical  Reporter,  May,  1829. 


IRRITATION.  59 

ness,  and  low  spirits.  The  pain  which  was  the  chief  suffering  com- 
plained of,  was  sharp  and  neuralgic  in  its  character,  and  varying  in  its 
seat,  being  sometimes  in  one  part  of  the  head  or  face,  sometimes  in 
another,  and  generally  on  the  left  side  only.  In  the  head  it  was  often 
limited  to  a  spot  which  might  be  covered  with  the  tip  of  the  finger, 
as  in  true  clavus  hystericus.  Headache  in  one  form  or  another  was 
brought  on  or  exaggerated  by  any  effort,  physical  or  mental :  it  was 
usually  relieved  by  lying  down  and  keeping  perfectly  still;  it  was 
scarcely  ever  absent  except  when  face-ache  had  its  turn  ;  and  sometimes 
it  was  so  continuous  and  oppressive  as  to  necessitate  remaining  in  bed 
for  days  together.  Nausea  and  sickness  were  its  frequent  accompani- 
ment, and  vomiting  and  great  prostration  were  its  common  termination. 
In  the  cervical  region  of  the  spine  there  were  considerable  tenderness 
and  a  disagreeable  feeling  of  weight,  and  pressure  there  brought  on  or 
increased  the  headache — the  pain  shooting  from  the  occiput  forwards 
— and  caused  a  feeling  of  great  nausea  and  oppression  at  the  prascordia. 
The  feet  were  always  cold;  "chills  and  flushes"  were  of  frequent  oc- 
currence, and  so  were  yawning,  sighing,  and  stretching  of  the  arms. 
Sleep  was  often  made  hideous  by  nightmare;  fits  of  lowness  of  spirits 
and  crying,  attended  by  a  sense  of  choking,  as  from  a  ball  or  knot  in 
the  throat,  and  followed  by  plentiful  gushes  of  pale,  limpid  urine,  were 
brought  on  by  the  most  trivial  causes ;  and  the  manner  and  appear- 
ance were  altogether  those  of  an  eminently  nervous  or  hysterical 
person.  Menstruation  was  regular,  neither  excessive  nor  deficient, 
and  it  could  not  be  said  that  the  sufferings  were  either  more  or  less  at 
this  time.  The  bowels  also  acted  properly,  and  (but  for  the  disposition 
to  pass  large  quantities  of  pale  urine,  which  has  been  already  men- 
tioned) so  did  the  kidneys  and  bladder. 

These  symptoms,  it  appears,  had  their  starting-point  about  twelve 
years  ago  in  the  shock  and  grief  caused  by  witnessing  the  death  of  a 
brother,  her  last  remaining  near  relative,  in  an  epileptic  fit,  and  ever 
since  this  time  they  have  continued  very  much  as  they  now  are,  with 
but  little  intermission.  Before  this  time  the  personal  history  of  the 
patient  was  tolerably  good,  but  not  so  her  family  history  ;  for,  in  addi- 
tion to  the  brother  whose  death  in  epilepsy  has  just  been  mentioned, 
it  appears  that  her  father  died  years  before  of  phthisis,  and  that  her 
mother  is  now  in  a  lunatic  asylum. 

Under  the  use  of  a  more  liberal  diet,  with  ammonia  and  calumba, 
and  with  occasional  blisters  to  the  nape  of  the  neck,  health  was  re- 
established in  little  more  than  a  month,  notwithstanding  the  fact  that 
several  days  at  the  commencement  were  wasted  in  overcoming  a  dis- 
like to  take  the  wine  and  medicine  necessary — in  converting,  in  fact, 
the  patient  from  a  firm  belief  in  teetotalism  and  homoeopathy. 

Towards  the  close  of  the  same  year,  1863,  this  young  lady  again 
returned  to  me,  looking  very  worn  and  thin,  with  all  her  old  symptoms 
in  force,  and  with  cough  and  difficulty  of  breathing  in  addition.  The 
cough  was  very  violent,  barking,  unattended  with  expectoration,  and 
often  carried  on  until  it  ended  in  retching  arid  vomiting.  The  diffi- 
culty of  breathing  was  chiefly  at  night:  usually  it  did  not  amount  to 
more  than  what  might  be  met  by  a  voluntary  effort  at  inspiration; 


60  DISEASES    OF   THE    SPINAL    CORD. 

now  and  then  it  seemed  to  deserve  the  name  of  asthma ;  almost  inva- 
riably it  was  accompanied,  not  by  a  feeling  of  a  ball  or  knot  in  the 
throat,  but  by  a  sharp  pain  in  the  left  hypochondrium,  or  else  by  severe 
aching  in  the  left  shoulder  and  down  the  left  arm.  Percussion  and 
auscultation  failed  to  bring  to  light  any  signs  of  disease  in  the  heart 
or  lungs,  but  pressure  along  the  spine  revealed  tenderness  in  the  cervi- 
cal and  upper  dorsal  regions,  in  the  latter  especially,  and  at  the  same 
time  brought  on  cough,  deep  inspirations,  pain  and  throbbing  at  the 
epigastrium,  and  a  feeling  of  great  faintness  and  breathlessness. 

On  this  occasion  a  very  fair  state  of  health  was  soon  re-established 
by  the  plan  of  treatment  which  proved  successful  in  the  first  instance. 

At  the  beginning  of  1865,  this  lady,  then  married,  again  required 
my  services.  For  three  weeks  before  my  seeing  her  she  had  been  in 
bed,  with  her  thighs  drawn  up  tightly  against  her  abdomen,  and  with 
her  heels  buried  in  her  nates.  This  contraction  was  unremitting 
during  the  waking  state,  and  only  partially  remitting  during  sleep:  it 
was  unattended  by  pain ;  and  it  could  be  partially  overcome,  for  a  time, 
without  causing  much  pain  in  the  contracted  muscles,  by  slow  and 
steady  extension.  The  headache  and  face-ache  had  gone  months  be- 
fore, and  so  had  the  pain  in  the  epigastrium  and  in  the  left  shoulder 
and  arm :  the  cough  and  difficulty  of  breathing  and  palpitation  were 
of  very  unfrequent  occurrence:  the  appetite  and  digestion  and  the 
action  of  the  bowels  were  tolerably  natural ;  and  what  was  complained 
of  now  were  colicky  pains  in  the  lower  part  of  the  abdomen,  pains  often 
very  severe  and  sickening  about  the  loins  and  hips,  and  in  the  region 
of  the  left  ovary,  with  constant  calls  to  pass  water,  and  much  pain  in 
the  urethra  in  attending  to  these  calls.  The  spine  was  now  tender, 
not  as  before,  in  the  cervical  and  dorsal  region,  but  low  down  in  the 
lumbar  region,  and  pressure  on  the  tender  part  brought  on  colicky 
pains  in  the  lower  part  of  the  abdomen,  and  a  cutting  pain  in  the 
urethra,  with  an  almost  irresistible  impulse  to  pass  water  then  and  there. 
Pressure  in  the  cervical  and  dorsal  regions  of  the  spine  gave  rise,  not 
to  the  marked  symptoms  produced  in  this  way  in  the  two  previous 
illnesses,  but  simply  to  a  disagreeable  thrill  all  over  the  body.  There 
was  no  numbness  or  tingling  in  the  legs  or  elsewhere,  and  no  hyper- 
sesthesia,  except  perhaps  to  a  very  trifling  degree  over  the  left  ovary. 
Tickling  the  soles  of  the  feet  gave  rise  to  painful  spasmodic  shocks  in 
the  legs,  to  a  disagreeable  thrill  passing  up  the  body  as  high  as  the 
throat,  and  to  the  involuntary  escape  of  a  small  quantity  of  urine. 
The  condition  as  to  general  health  was  tolerably  good — much  better 
than  during  the  two  previous  illnesses ;  and,  in  fact,  the  only  sign  of 
disorder,  in  addition  to  those  which  have  been  indicated  (and  this  can 
scarcely  be  reckoned  as  such),  was  the  absence  of  menstruation  since 
the  birth  of  a  child  about  three  months  ago. 

Somewhat  more  than  twelve  months  ago,  after  having  been  quite 
well  for  the  year  previously,  this  patient  married  and  became  pregnant. 
In  the  early  months  of  pregnancy  she  had  much  headache,  depres- 
sion, weakness,  and  sickness ;  but  after  a  while  these  symptoms 
passed  off,  and  everything  went  on  smoothly  and  satisfactorily  until 
two  months  after  confinement,  when  her  baby  died  suddenly.  And  then 


IERITATION.  61 

began  her  present  troubles.  The  fretting  about  her  baby  brought 
back  the  old  headaches,  the  headaches  produced  great  sleeplessness 
and  irritability  of  the  stomach,  and  then  came  on  a  state  of  uncon- 
trollable fidgetiness  which  kept  her  incessantly  moving  about  until 
her  legs,  one  leg  especially,  failed  altogether,  and  obliged  her  to  take 
to  her  bed.  The  very  next  morning  her  legs  had  become  contracted, 
and  she  herself  is  convinced  that  this  change  for  the  worse,  as  she 
regards  it,  was  brought  about  by  the  pain  and  loss  of  blood  produced 
by  introducing  a  large  speculum  and  by  applying  leeches  to  the  os 
uteri  on  the  previous  evening. 

The  treatment  on  this  occasion  consisted  chiefly  in  a  liberal  allow- 
ance of  food  and  wine,  in  repeated  blisterings  to  the  lumbar  region  of 
the  spine,  and  in  the  administration  of  bromide  of  potassium  and  ammo- 
nia ;  the  result  was  the  cessation  of  the  contractions  in  about  three 
weeks,  and  the  complete  re-establishment  of  health  in  about  two  months 
and  a  half. 

In  commenting  upon  this  case  with  the  view  of  separating  the 
general  phenomena  of  spinal  irritation  from  the  particular,  I  take  the 
following  as  the  points  which  most  deserve  to  be  attended  to,  namely, 
these : — spinal  tenderness,  neuralgia,  spasmodic  cough  and  difficulty 
of  breathing,  palpitation  and  vascular  throbbings,  nausea,  vomiting, 
and  eructations,  and  irritability  of  the  bladder,  all  in  connection  with 
spinal  tenderness ;  the  connection  of  particular  symptoms  or  groups  of 
symptoms  with  tenderness  in  particular  parts  of  the  spine;  prolonged 
muscular  contraction  ;  no  paralysis  of  the  limbs ;  no  paralysis  of  the 
bladder  or  rectum  ;  no  numbness;  variability  and  inconstancy  of  the 
symptoms;  a  nervous  constitution. 

Spinal  tenderness. — In  the  great  majority  of  cases  this  symptom 
would  seem  to  be  present  in  spinal  irritation  and  absent  in  spinal 
meningitis,  myelitis,  or  spinal  congestion,  acute  or  chronic.  It  would 
seem,  indeed,  to  deserve  to  be  regarded  as  the  pathognornonic  symptom 
of  spinal  irritation;  for  in  the  few  cases  of  spinal  meningitis,  myelitis, 
or  spinal  congestion  in  which  it  is  met  with,  there  is  reason  to  believe 
that  its  presence  may  be  accounted  for  by  the  association  of  the  phe- 
nomena of  irritation  with  those  of  inflammation  or  congestion.  At 
any  rate,  it  is  certainly  the  rule  that  spinal  irritation  without  spinal 
inflammation  or  congestion  is  accompanied  by  spinal  tenderness,  and 
that  spinal  inflammation  and  congestion  without  spinal  irritation  is 
not  accompanied  by  spinal  tenderness.  Spinal  tenderness,  however, 
can  scarcely  be  spoken  of  as  a  prominent  symptom  in  spinal  irritation. 
It  is  often  not  complained  of  until  it  is  specially  inquired  after ;  and  now 
and  then  its  existence  is  not  even  suspected  by  the  patient  until  he  or 
she  is  made  to  wince  under  pressure  applied  to  the  spine.  In  a  few 
cases  which  from  their  symptoms  would  seem  to  come  under  no  other 
head  than  that  of  spinal  irritation,  there  is  no  spinal  tenderness — only 
five  such  cases  are  met  with  among  the  148  cases  brought  together  by 
the  brothers  Dr.  and  Mr.  Griffin,  and  these  may  without  difficulty  be 
in  great  measure  explained  away  ;  but  such  cases  are  much  too  excep- 
tional and  doubtful  to  throw  discredit  on  the  rule  in  question,  that 
spinal  irritation  and  spinal  tenderness  go  together.  Spinal  tenderness, 


62  DISEASES    OF   THE    SPINAL    CORD. 

however,  does  not  appear  to  be  equally  marked  in  all  forms  of  spinal 
irritation.  It  appears  to  be  much  less  marked  where  the  irritation 
shows  itself  in  spasm  and  prolonged  muscular  contraction  than  in  the 
cases  where  it  shows  itself  in  pain ;  and  it  is  certainly  absent  in  te- 
tanus, which  in  one  sense  may  be  looked  upon  as  the  manifestation  of 
spinal  irritation  in  its  most  aggravated  form. 

Nervous  pains,  often  in  connection  with  tenderness  in  a  particular  part 
of  the  spine. — Nervous  pains,  neuralgias,  in  one  place  or  another,  often 
intermittent  and  more  or  less  regularly  periodical,  and  often  shifting 
suddenly  from  one  place  to  another,  are  a  very  common,  perhaps  the 
most  common,  symptom  in  spinal  irritation.  They  are  often  brought 
on  or  exaggerated  by  lifting  any  weight,  by  twisting  or  straining  the 
back  in  any  way,  or  by  any  effort,  mental  or  physical:  and  as  often 
they  are  relieved,  to  some  extent  at  least,  by  lying  down.  Very  often, 
also,  there  is  tenderness  in  the  portion  of  the  spine  corresponding  to 
the  insertion  of  the  affected  nerves — in  the  upper  cervical  region,  where 
the  pains  are  in  the  scalp  (clavus  hystericus,  megrim,  and  others),  face, 
or  neck ;  in  the  lower  cervical  region,  where  they  are  in  the  upper 
extremities,  shoulders,  and  upper  part  of  the  thorax  ;  in  the  dorsal 
region,  where  they  are  in  the  lower  part  of  the  thorax  and  upper  part 
of  the  abdomen  (pleurodynia,  gastrodynia,  infra-mammary  stitch,  and 
others)  ;  in  the  lumbar  and  cervical  regions,  where  they  are  in  the 
lower  part  of  the  abdomen,  hips,  loins,  and  lower  extremities.  In  the 
majority  of  cases  the  pain  would  not  seem  to  be  in  the  part  of  the  spine 
which  is  tender,  or  in  any  other  part.  In  some  cases  there  may  be 
aching  in  some  part  of  the  spine,  or  else  a  sense  of  weight  and  heat; 
but  I  am  very  much  inclined  to  believe  that  these  last  mentioned 
symptoms,  and  "  back  ache"  generally,  have  often  to  be  referred  to  spi- 
nal congestion  rather  than  to  spinal  irritation  in  its  uncomplicated  form. 
When  the  spinal  tenderness  is  very  great,  slight  pressure  will  often 
cause  pain  to  strike  from  the  tender  spot  of  the  spine  to  the  distant 
seat  of  pain,  or  will  bring  about  or  exaggerate  this  pain.  This  fact  is 
illustrated  in  the  case  I  have  given,  and  better  still  in  some  of  the  cases 
related  by  the  Griffin  brothers.  In  one  of  these  cases,  for  example, 
where  the  whole  spinal  column  was  found  to  be  acutely  tender,  "  pres- 
sure of  the  first  or  second  vertebra  occasioned  pain,  which  shot  for- 
wards from  the  occiput  to  the  brow;  a  little  lower,  pain  was  excited 
at  the  larynx  ;  on  pressing  one  of  the  lower  cervical,  it  occurred  at  the 
point  where  it  dips  behind  the  sternum  ;  on  pressing  the  upper  dorsal, 
at  the  middle  of  the  sternum;  from  the  third  or  fourth  dorsal  to  the 
eighth  or  ninth,  it  was  excited  at  the  ensiform  cartilage ;  yet  lower,  at 
the  sides ;  and  in  the  lumbar  vertebras,  pain  was  excited  in  the  iliac 
and  pubic  regions"  (p.  19).  And  in  another  case,  where  there  was 
some  tenderness  of  the  middle  cervical  vertebrae,  and  acute  tenderness 
from  the  fourth  dorsal  to  the  eighth  or  ninth,  "  pressure  on  any  of  those 
last,  especially  the  seventh  or  eighth,  brought  on  violent  pain,  which 
darted  forwards  to  the  ensiform  cartilage.  When  the  last  mentioned 
vertebra  was  pressed  upon,  the  patient  said  that  she  thought  her 
'  heart  would  break' "  (p.  119).  The  pain  is  often  curiously  localized : 
sometimes  it  gives  the  idea  of  a  nail  being  driven  into  the  part,  as  in 


IRRITATION.  63 

clavus  hystericus;  sometimes  the  feeling  produced  by  it  is  as  if  a 
walnut  or  other  hard  substance  were  pressed  under  a  tight  belt ;  some- 
times it  is  very  severe,  and  neuralgic  in  its  character  rather  than  rheu- 
matic: and  not  unfrequently,  when  it  has  existed  some  time,  the 
painful  part  becomes  tender  on  pressure.  Most  generally  this  morbid 
sensation  is  in  the  form  of  pain,  but  now  and  then  it  may  take  that  of 
cold,  tingling,  itching,  or  some  other  feeling  which  is  disagreeable 
rather  than  painful.  The  amount  of  constitutional  disturbance  attend- 
ing the  pain  varies  very  much,  but  it  is  usually  comparatively  trifling, 
and,  as  it  would  seem,  quite  out  of  proportion  to  the  degree  of  suf- 
fering. 

Nausea,  retching,  vomiting,  eructation,  &c.,  often  in  connection  with 
tenderness  in  a  particular  part  of  the  spine. — These  are  common  symp- 
toms in  spinal  irritation:  next  to  pain,  indeed,  they  are  perhaps  the 
most  common.  They  are  also  intimately  connected  with  certain  forms 
of  pain,  especially  cephalalgia  and  gastrodynia,  sometimes  preceding, 
sometimes  accompanying,  but  more  generally  following,  the  pain.  As 
regards  the  particular  part  of  the  spine  which  is  likely  to  be  tender 
when  the  stomach  is  the  seat  of  irritation,  the  Griffin  brothers  say  that 
"  nausea  and  vomiting  appear  to  bear  more  relation  to  tenderness  of 
the  cervical  spine,  pain  of  stomach  to  tenderness  of  the  dorsal ;  but 
that  where  there  was  soreness  of  both,  nausea  and  vomiting  was  still 
more  frequent,  and  pain  of  stomach  scarcely  ever  absent."  The  epi- 
gastric disorder  in  these  cases  is  generally  accompanied  with  tenderness 
on  pressure,  not  merely  in  the  spine  but  also  in  the  epigastrium  and 
in  the  left  hypochondrium — with  those  three  patches  of  tenderness 
which  M.  Briquet  speaks  of  as  the  "  tripled  hysterique" — as  the  tripod 
upon  which  the  diagnosis  of  hysteria  rests. 

Spasmodic  cough,  difficulty  of  breathing,  &c.,  often  in  connection  -with 
tenderness  in  a  particular  part  of  the  spine. — These  again  are  symptoms 
which  are  common  enough  in  spinal  irritation,  and  mostly  so,  as  it 
would  seem,  when  the  tenderness  in  the  spine  is  in  the  cervical  and 
upper  dorsal  region. 

Palpitation,  &c.,  often  in  connection  with  tenderness  in  a  particular  part 
of  the  spine. — Palpitation  is  another  symptom  of  spinal  irritation  which 
seems  to  be  oftenest  met  with  wljen  there  is  tenderness  in  the  upper 
half  of  the  spine.  It  seems  to  be  not  unfrequently  associated  with  a 
feeling  of  epigastric  pulsation,  and  with  nausea,  vomiting,  and  other 
signs  of  gastric  disorder.  Vascular  throbbings  in  other  places,  as  in 
the  temples,  and  "chills  and  flushes,"  and  a  disposition  to  syncope, 
and  other  signs  of  disturbed  balanca  in  the  circulation,  may,  and  often 
do,  go  hand  in  hand  with  the  palpitation,  and  seem,  to  have  to  do  with 
the  same  condition  of  the  spine. 

Irritability  of  the  bladder,  often  in  connection  with  tenderness  in  a  particu- 
lar part  of  the  spine. — This  was  a  marked  symptom  in  the  case  which 
I  have  related  when  the  seat  of  spinal  tenderness  shifted  to  the  lumbar 
region,  and  it  seems  to  be  a  very  common,  if  not  a  constant  symptom, 
in  cases  in  which  the  tenderness  is  in  this  region. 

The  connection  of  particular  symptoms  or  groups  of  symptoms  ivith 
tenderness  in  particular  regions  of  the  spine. — The  data  best  calculated  to 


64  DISEASES    OF   THE    SPINAL    CORD. 

illustrate  this  connection  are  those  supplied  by  Dr.  and  Mr.  Griffin* 
These  consist  of  no  less  than  148  cases,  of  which  26  are  in  males,  49 
in  married  women,  and  73  in  girls.  In  these  148  cases,  the  spinal 
tenderness  was  in  the  cervical  region  in  28,  in  the  cervical  and  upper 
dorsal  region  in  46,  in  the  dorsal  region  in  23,  in  the  dorsal  and  lumbar 
region  in  15,  in  the  lumbar  region  in  13,  and  in  the  spine  generally  in 
23.  In  the  following  table  the  prominent  symptoms  connected  with 
each  one  of  these  forms  of  spinal  tenderness  is  set  forth  in  a  way 
which  requires  no  comment  except  this — that  this  grouping  of  symp- 
toms with  tenderness  in  particular  parts  of  the  spine  must  only  be 
looked  upon  as  approximating  to  the  truth,  and  that  now  and  then 
any  symptom  may  appear  out  of  the  order  in  which  it  is  set  down. 


Region  of  Spinal  Tenderness. 

A.   Cervical  region. 
Cases  28  in  number. 


B.  Cervical  and  Dorsal  region. 
Cases  46  in  number. 


C.  Dorsal  region. 
Cases  23  in  number. 


D.  Dorsal  and  Lumbar  region. 
Cases- 15  in  number. 


E.  Lumbar  region. 
Cases  13  in  number. 


F.  All  regions  together. 
Cases  23  in  number. 


Prominent  Symptoms. 

Headache,  nausea,  vomiting,  face- 
ache,  fits  of  insensibility,  cough, 
pains  in  the  upper  extremities,  etc. 

*#*  Nausea  and  vomiting  in  5 
cases,  pains  of  stomach  in  2  only. 

In  addition  to  the  symptoms  in 
group  A,  pain  of  stomach  and  sides, 
pyrosis,  palpitation,  oppression. 

*#*  Pain  of  stomach  in  34  cases, 
nausea  and  vomiting  in  10. 

Pain  in  the  stomach  and  sides, 
cough,  oppression,  fits  of  syncope, 
hiccup,  eructations. 

*#*  Pain  in  the  stomach  in  al- 
most all  these  cases,  nausea  or 
vomiting  in  only  one. 

In  addition  to  the  symptoms  in 
group  c,  pains  in  the  abdomen, 
loins,  hips,  lower  extremities,  dys- 
ury,  and  ischury. 

*#*  Nausea  in  only  one  case. 

Pains  in  the  lower  part  of  the 
abdomen,  testes,  or  lower  extremi- 
ties, dysury,  ischury,  disposition  to 
paralysis  in  lower  extremities. 

*^.*  Retching  and  spasm  of  the 
stomach  in  one  case  only. 

A  combination  of  the  foregoing 
groups  of  symptoms,  one  group 
changing  into  another  as  the  spinal 
tenderness  becomes  more  marked 
in  one  region  than  in  another. 


IRRITATION.  65 

Prolonged  muscular  contraction. — This  is  a  very  conspicuous  symp- 
tom in  the  case  which  serves  as  my  text,  and  it  is  no  uncommon 
symptom  in  other  cases  of  spinal  irritation.  The  lower  extremities 
appear  to  be  the  parts  most  commonly  affected,  one  or  both  of  them ; 
but  the  upper  extremities  can  claim  no  exception,  nor  even  the  muscles 
of  the  jaws  and  neck,  trismus  or  torticollis  being  among  the  results  in 
this  latter  case.  "  Occasionally,"  says  Mr.  Teale,  "  there  is  an  inability 
to  perform  complete  extension  of  the  elbow,  the  arm  appearing  re- 
strained by  the  tendon  of  the  biceps,  pain  and  tightness  being  produced 
in  this  part  when  extension  is  attempted  beyond  a  certain  point ;" 
and  to  this  fact  I  can  testify.  Moreover,  I  can  testify  as  to  the  not 
unfrequent  occurrence  of  long-continued  closing  of  the  fingers  and 
thumb  upon  the  palm.  The  rule  appears  to  be,  for  the  extremities  to 
be  affected  before  the  trunk  or  head.  This  contraction,  which  is 
generally  painless,  may  be  prolonged  for  weeks  or  even  months  con- 
tinuously even  during  sleep,  or  with  occasional  intermissions  of  uncer- 
tain duration ;  and  the  attacks,  primary  or  secondary,  are  usually 
found  to  begin  and  end  suddenly  and  unexpectedly.  The  relations 
between  this  form  of  contraction  and  that  which  occurs  in  other  cases, 
especially  in  tetanus  and  in  that  somewhat  vague  disorder  to  which 
Dr.  Trousseau  has  given  the  name  of  tetany  (te'tanie),  are  not  very  easily 
determined.  In  tetanus,  with  very  rare  exceptions,  the  contraction  is 
painful,  especially  in  the  paroxysmal  bouts,  and  the  order  in  which  it 
attacks  the  body  is  different — first,  the  jaws ;  then  the  trunk ;  and  the 
extremities  only  at  a  late  period,  if  at  all.  In  tetany,  as  in  tetanus, 
the  contraction  is  painful,  but  the  order  in  which  the  body  is  attacked 
is  different  to  that  which  is  observed  in  tetanus,  centripetal  not  cen- 
trifugal— first,  the  extremities,  then  the  trunk  or  head;  the  contraction, 
in  fact,  being  confined  to  the  extremities,  except  in  cases  of  unusual 
severity.  In  the  way  in  which  it  affects  the  extremities  first,  and  often 
exclusively,  the  contraction  of  tetany  agrees  with  the  contraction 
under  consideration,  but  in  other  respects  it  differs.  It  differs,  espe- 
cially, in  being  ushered  in  and  accompanied  by  symptoms  which  do 
not  seem  to  form  part  and  parcel  of  simple  spinal  irritation  ;  namely, 
tingling  and  some  degree  of  anaesthesia,  and  also  (so  it  is  said)  in  the 
form  of  the  contracted  hand  being  peculiar — like  that  which  the  hand 
of  the  accoucheur  takes  in  order  to  be  introduced  into  the  vagina — 
and  in  the  possibility  of  bringing  on  the  contraction  by  firm  pressure 
upon  the  principal  nerves  or  arteries  of  the  affected  muscles.  It  may 
be  questioned,  however,  whether  there  are  absolutely  fixed  lines  of 
division  between  these  different  forms  of  prolonged  contraction  and 
whether  the  difference  which  exists  may  not  be  accounted  for  as  the 
result  of  different  degrees  of  irritation,  affecting,  it  may  be,  different 
parts  of  the  spinal  cord.  It  may  be  questioned,  also,  whether  a  suffi- 
cient case  is  made  out  for  describing  tetany  as  a  definite  disorder,  and 
whether  it  is  not  rather  a  form  of  spinal  irritation  complicated  with 
some  graver  spinal  disease — spinal  meningitis,  myelitis,  spinal  con- 
gestion— in  varying  proportions.  The  association  of  tingling  and 
numbness  with  the  prolonged  contraction  is,  as  it  seems  to  me,  a 
reason  for  an  affirmative  conclusion.  At  any  rate,  prolonged  muscu- 
5 


66  DISEASES    OF   THE    SPINAL    CORD. 

lar  contraction,  be  its  significancy  in  tetanus  or  tetany  what  it  my 
must  be  looked  upon  as  a  not  unfrequent  symptom  in  simple  spinal 
irritation — as  a  symptom,  too,  which  is  usually  of  no  very  grave  im- 
port.    Of  this  there  need  be  no  doubt. 

No  paralysis  of  the  limbs. — In  the  case  I  have  given  in  illustration 
there  was  great  weakness  of  the  legs,  and  one  leg  seemed  to  "drag" 
immediately  before  the  contractions  came  on.  There  was  a  disposition 
to  paralysis  in  the  legs,  but  not  more  than  this ;  nor  do  I  find  paralysis 
of  the  limbs  among  the  symptoms  of  spinal  irritation  strictly  so  called. 
There  is,  no  doubt,  a  connection  between  paralysis  and  spinal  irritation 
which  cannot  be  overlooked  ;  and  under  that  form  of  paralysis  which 
is  known  as  "  hysterical  paralysis,"  and  about  which  more  will  have 
to  be  said  in  due  time,  and  under  spinal  irritation,  there  is  a  common 
basis.  As  it  seems  to  me,  however,  it  is  pathologically  as  well  as 
physiologically  incorrect  to  speak  of  hysterical  paralysis  as  a  symptom 
of  spinal  irritation.  Also,  it  seems  to  me,  the  right  place  of  this  pa- 
ralysis is  after  spinal  irritation,  not  along  with  it,  when  the  capability 
of  morbid  action  which  is  implied  in  the  term  irritation  is  worn  out ; 
and  so  in  the  other  exceptional  cases  in  which  paralysis  is  connected 
with  spinal  irritation,  it  will,  I  believe,  be  found  on  careful  examina- 
tion that  the  paralysis  is  not  a  symptom  of  actual  spinal  irritation,  but 
of  a  state  of  vascular  change  into  which  this  irritation  may  issue  and 
has  issued — spinal  congestion,  it  may  be,  or  even  myelitis. 

No  paralysis  of  the  bladder  or  bowel. — The  remarks  which  have  just 
been  made  apply  equally  to  paralysis  of  the  bladder  or  bowel.  Paraly- 
sis in  either  of  these  organs,  or  even  a  disposition  to  it,  is  rarely  met 
with  in  any  case  which  can  be  strictly  brought  under  the  head  of 
spinal  irritation ;  and  in  the  few  exceptional  instances  which  do 
occur,  it  is  plain  enough,  when  the  matter  is  fairly  inquired  into, 
that  the  boundary  has  been  passed  which  separates  the  state  of 
irritation  from  the  state  of  exhaustion,  and  that,  in  fact,  the  case  is 
no  longer  one  of  simple  spinal  irritation. 

No  numbness. — Numbness,  again,  is  a  symptom  which  is  scarcely 
ever  met  with  in  cases  to  which  the  name  of  spinal  irritation  is  strictly 
applicable,  and,  when  it  is  met  with,  it  is  easily  accounted  for.  In 
short,  the  relationship  of  numbness  and  paralysis  to  spinal  irritation 
appears  to  be  one  and  the  same,  the  numbness  and  the  paralysis  being 
alike  connected,  not  with  the  state  of  morbid  action  called  irritation, 
but  with  the  after-state  of  morbid  inaction  for  which  exhaustion  seems 
to  be  one  of  the  appropriate  names. 

Variability  and  inconstancy  of  symptoms. — One  most  characteristic 
feature  of  spinal  irritation  is  the  way  in  which  one  symptom  or  group 
of  symptoms  may  change,  and  change  suddenly,  into  another  symp- 
tom or  group  of  symptoms.  It  is  now  this  disease  which  is  simulated, 
now  that,  there  being  scarcely  any  disease  which  may  not  be  simu- 
lated :  at  one  time  the  head  is  affected,  at  another  the  chest,  at  another 
the  abdomen  or  the  extremities:  and  the  only  thing  constant  among 
these  ever-shifting  phenomena  appears  to  be  this — that  the  spinal 
tenderness  changes  from  one  part  to  another  in  a  manner  which  is 


IRRITATION.  67 

intelligible  enough  when  the  connection  of  the  spinal  nerves  with  the 
affecte4  part  is  taken  into  consideration. 

A  nervous  constitution. — The  subjects  of  spinal  irritation,  with  few  if 
any  exceptions,  may  be  spoken  of  as  hysterical,  hypochondriacal,  or 
nervous.  They  have,  in  fact,  that  nervous  constitution  which  Whytt, 
following  in  the  steps  of  Sydenham,  showed  to  be  the  common  basis 
of  hysteria  and  hypochondriasis.  First  in  order  among  the  signs  of 
this  constitution  comes  that  sign  which  Sydenham  regarded  as  pathog- 
nomonic  of  hysteria  and  hypochondriasis — namely,  a  proneness  to  pass, 
under  or  after  strong  emotion  or  excitement,  large  quantities  of  pale 
limpid  urine.  Then  come  other  signs  scarcely  less  characteristic: 
proneness  to  tenderness,  not  only  in  some  part  of  the  spinal  column, 
but  also  in  the  epigastrium  and  left  hypochondrium — le  trepied  hys- 
terique  of  Dr.  Briquet  already  referred  to ;  proneness  to  sudden  and 
distressing  flatulent  distension  of  the  stomach  and  bowels,  with  loud 
rumblings  and  explosions,  and  with  a  feeling  of  a  ball  rolling  about, 
first  in  the  left  flank,  an'd  then  mounting,  or  tending  to  mount,  into 
the  throat,  where  it  gives  rise  to  a  sense  of  choking  and  to  repeated 
acts  of  swallowing;  proneness  to  bursts  of  crying  and  sobbing  or  of 
laughing;  proneness  to  sighing,  yawning,  and  stretching  the  arms; 
and  proneness  to  fits  of  convulsive  agitation  and  struggling.  Then 
come  a  promiscuous  series  of  signs :  proneness  to  erratic  pains  of  a 
neuralgic  character,  breathless  ness,  nervous  cough,  palpitation,  throb- 
bing in  the  temples,  epigastrium,  and  elsewhere;  "flushes  and  chills," 
syncope,  hiccup,  nausea,  vomiting,  aversion  to  food  or  unnatural 
craving  for  it,  heartburn,  oppression  at  the  praecordia,  languor,  debi- 
lity, fidgetiness,  tremulousness,  vertigo  (especially  on  rising  hastily), 
ringing  in  the  ears,  "animus,  nee  sponte,  varius  et  mutabilis,"  fanci- 
fulness  and  inability  to  discriminate  between  fact  and  fiction,  undue 
lowness  of  spirits  or  the  contrary,  and  a  host  of  other  symptoms  whose 
name  is  legion.  Not  only,  indeed,  is  the  name  of  these  different 
symptoms  legion,  but  there  is  ever  going  on  a  process  of  mutual  meta- 
morphosis in  the  symptoms  themselves ;  and,  in  conclusion,  it  is  this 
very  hysterical  or  hypochondriacal  variability  and  mutability  of  the 
symptoms  which  must  be  looked  upon  as  the  great  characteristic  of 
the  nervous  constitution. 

2.  POST  MORTEM  APPEARANCES. — The  morbid  structural  changes 
strictly  belonging  to  spinal  irritation  are  nil.  The  disease  is  nervous 
or  functional  in  its  character,  and  on  this  account  it  leaves  no  obvious 
traces  after  death.  Still,  as  Dr.  Copland  wisely  says,  "an  affection 
which  may  with  justice  be  viewed  as  functional  to-day — as  spinal  irri- 
tation merely — may  be  inflammation  on  the  morrow,  and  rapidly 
followed  by  the  consequences  of  inflammation."  Such  a  termination, 
however,  is  altogether  exceptional :  and  when  it  does  occur,  the  his- 
tory during  life  will  show  very  clearly  that  any  traces  of  inflammation 
which  are  met  with  after  death  are  to  be  ascribed,  not  to  irritation, 
but  to  inflammation.  How  far  irritation,  which  involves  in  its  very 
essence,  as  I  believe,  capillary  contraction  and  bloodlessness,  not 
capillary  paralysis  and  congestion,  may  involve  changes  which  are 


68  DISEASES    OF    THE    SPINAL    COED. 

opposed  to  inflammation — deficiency  of  blood  and  organic  changes 
brought  on  by  the  part  being  starved  for  want  of  blood — remains  to 
be  seen.  I  take  it  that  such  changes  would  have  been  found  if  they 
had  been  looked  for  with  the  same  amount  of  care  which  has  been 
expended  in  the  search  for  inflammatory  changes:  but  the  investiga- 
tions have  yet  to  be  made  which  will  verify  or  disprove  the  conjec- 
ture. 

3.  CAUSES. — Neglect  of  gymnastic  training,  insufficiency  of  wine  or 
other  alcoholic  drinks,  over-indulgence  in  sexual  matters,  onanism, 
would  seem  to  deserve  a  conspicuous  place  among  the  causes  of  spinal 
irritation.     Tt  is  idle,  however,  to  weigh  the  importance  of  particular 
causes,  or  even  to  attempt  to  individualize  them,  and  it  is  enough  to 
be  content  with  the  broad  fact  that  everything  which  tends  to  induce  a 
nervous  habit — that  is,  everything  which  exhausts  vital  power — must 
be  reckoned  as  a  cause.     I  believe  that  the  starting-point  of  the  disor- 
der will  very  often  be  found  in  some  strain,  or  blow  to  the  back,  and 
I  also  believe  that  a  congenital  predisposition  may  also  be  detected  in 
very  many  cases. 

4.  DIAGNOSIS. — The  fundamental  question  for  consideration  in  this 
place  is  how  to  distinguish  between  functional  and  organic  affections 
of  the  spinal  cord,  and  this  question  fortunately  is  one  which  is  less 
difficult  to  answer  than  it  might  seem  to  be  at  first  sight.     In  fact,  the 
characteristics  of  spinal  irritation  indicated  by  the  Griffin  brothers,  are 
sufficient  of  themselves  to  supply  the  answer  to  any  one  who  has 
tolerably  clear 'ideas  respecting  the   principal  diseases   with   which 
spinal  irritation  may  be  confounded.    These  characteristics  are  :   "  1st. 
The  pain  or  disorder  of  any  particular  organ  being  altogether  out  of 
proportion  to  the  constitutional  disturbance.  2d.  The  complaints,  what- 
ever they  may  be,  being  usually  relieved  by  the  recumbent  posture, 
and  always  increased  by  lifting  weights,  bending,  stooping,  or  twisting 
the  spine.     3d.  The  existence  of  tenderness  at  that  part  of  the  spine 
which  corresponds  with  the  disordered  organ,  and  the  increase  of  pain 
in  that  organ  by  pressure  on  the  corresponding  region  of  the  spine. 
4th.  The  disposition  to  the  sudden  transference  of  the  disordered  action 
from  one  organ  or  part  to  another,  or  the  occurrence  of  hysterical  symp- 
toms in  affections  apparently  acute;  and  5th.  The  occurrence  of  fits  of 
yawning  or  sneezing,  which,  though  not  very  common  symptoms,  yet, 
as  rarely  ever  occurring  in  acute  organic  disease,  may  generally  be 
considered  as  characteristics  of  nervous  irritation." 

In  the  diseases  of  the  spinal  cord  which  have  already  been  under 
consideration — spinal  meningitis,  myelitis,  spinal  congestion,  and  te- 
tanus— it  has  been  seen  that  it  is  the  rule  for  the  spine  not  to  be  ten- 
der on  pressure,  and  in  spinal  irritation  it  has  been  seen  that  such  ten- 
derness is  so  constant  as  to  deserve  being  reckoned  as  the  distinctive 
feature.  Here,  then,  is  a  point  of  difference  which  will  serve  as  a 
guide  to  a  correct  diagnosis  in  several  important  cases  in  which  guid- 
ance is  necessary — which  will  serve  as  a  guide  in  almost  all  cases 
except  in  that  with  which  spinal  irritation  is  most  readily  confounded. 
This  case,  which  is  strumous  disease  of  the  vertebra,  is  one  in  which 


IRRITATION".  69 

spinal  tenderness  is  also  present,  as  well  as  many  other  symptoms  of 
spinal  irritation — pain  in  the  side,  stomach,  or  bowels,  cough,  oppres- 
sion, tightness  around  the  waist,  and  so  on — and  in  which  relief  is  ob- 
tained by  reclining.  Nay,  there  may  even  be  in  spinal  irritation  a 
yielding  and  projection  of  the  tender  vertebrae,  with  some  puffiness  of 
the  overlying  skin,  which  simulates  in  no  imperfect  manner  the  earlier 
stage  of  angular  curvature.  There  are  many  resemblances,  in  fact,  but, 
as  Dr.  and  Mr.  Griffin  have  pointed  out,  there  are  also  certain  differ- 
ences which  are  so  well  marked  as  not  to  leave  the  diagnosis  in  doubt. 
Thus  it  is  found:  "1st.  That  strumous  disease  of  the  vertebrae  attacks 
the  young,  and  most  frequently  those  under  the  age  of  puberty,  who 
are  least  of  all  liable  to  be  affected  by  spinal  irritation.  2d.  That 
disease  of  the  vertebrae,  when  attacking  young  girls,  is  seldom  accom- 
panied by  symptoms  of  a  purely  hysterical  character,  while  any  serious 
irritation  of  the  cord  can  scarcely  exist  without  them.  3d.  That  an 
apparent  prominence  of  the  tender  portion  of  the  spine,  which  some- 
times exists  in  case  of  irritation,  is  never  strictly  angular;  for,  if  four 
or  five  of  the  vertebrae  seeni  to  project,  the  prominence  is  nearly  equal 
in  all,  whereas  in  caries  of  the  bones  it  is  greatest  in  the  middle,  the 
prominence  depending,  in  fact,  on  a  slight  puffing  of  the  ligaments  or 
investments  of  the  spine,  and  not  on  displacement  or  curvature.  4th. 
That  absolute  paralysis  of  the  lower  limbs  is  a  rare  consequence  of 
irritation,  and  a  frequent  one  of  caries  of  the  bones.  5th.  That  the 
general  health  suffers  less  in  the  former  complaint,  and  it  is  not  at- 
tended with  the  look  of  serious  organic  disease  which  is  indicative  of 
the  latter.  6th.  That  the  constitution  of  the  patient  may  also  prove 
useful  as  a  guide,  the  disposition  to  spinal  irritation,  as  well  as  to  scro- 
fula being  hereditary." 

5.  PROGNOSIS. — However  urgent  the  symptoms  may  be,  the  prog- 
nosis in  spinal  irritation  is  favourable  rather  than  unfavourable.  It  must 
always  be  borne  in  mind,  however,  that  spinal  irritation  is  a  state  which 
may  issue  in  inflammatory  or  other  organic  changes  in  the  cord  or  in  its 
membranes,  and  that  a  favourable  prognosis  must  be  qualified  by  this 
contigency,  especially  in  those  cases  in  which  there  is  some  obvious 
vice  of  the  constitution — scrofulous,  gouty,  rheumatic,  syphilitic,  or 
other. 

6.  TREATMENT. — "Local  depletion  by  leeches  or  cupping,"  says 
Mr.  Teale,  "and  counter-irritation  by  blisters  to  the  affected  portion 
of  the  spine,  are  the  principal  remedies.     A  great  number  of  cases  will 
frequently  yield  to  the  single  application  of  any  of  these  means.    Some 
cases,  which  have  even  existed  for  several  months,  I  have  seen  perfectly 
relieved  by  the  single  application  of  a  blister  to  the  spine,  although  the 
local  pains  have  been  ineffectually  treated  by  a  variety  of  remedies  for 
a  great  length  of  time."     Of  the  efficacy  of  blisters  in  these  cases  I 
have  had  abundant  proof.     As  to  the  good  effects  of  local  depletion  [ 
have  had  less  experience,  partly  because  I  found  that  the  blisters  were 
sufficient  of  themselves,  and  partly  because  I  believe  that  the  state  of 
irritation  is  associated  with  a  state  of  capillary  contraction  and  blood- 
lessness,  and  not  with  a  state  of  capillary  paralysis  and  congesiion. 


70  DISEASES    OF    THE    SPINAL    CORD. 

Still,  I  can  well  believe  that  there  are  many  mixed  cases  in  which  irri- 
tation has  issued  in  some  degree  of  capillary  paralysis  and  congestion, 
especially  in  the  skin  at  the  seat  of  spinal  tenderness,  and  in  which 
this  state  will  be  greatly  relieved  by  local  depletion. 

As  regards  medicine,  I  should  certaintly  be  disposed  to  trust  most 
in  common  tonics — quinine,  steel,  or  cod-liver  oil ;  to  the  latter  in  con- 
junction with  some  preparation  of  phosphorus  most  of  all,  perhaps. 
And  certainly  I  should  be  disposed  to  fight  against  pain  and  spasrn, 
as  I  have  sufficiently  explained  elsewhere,  by  remedies  which  rouse  the 
circulation  to  greater  activity,  and  not  by  those  which  have  a  contrary 
action.  Nay,  I  should  even  have  more  confidence,  as  a  local  application 
for  pain,  in  some  application  which  would  produce  a  hyperasmic  con- 
dition of  the  skin,  than  in  any  one  which  had  a  deadening  effect  upon 
the  sensitiveness  of  the  part. 

It  is,  no  doubt,  an  indispensable  part  of  the  treatment  to  avoid  stand- 
ing or  walking  to  the  extent  of  producing  fatigue,  but  there  would 
seem  to  be  no  necessity,  except  as  a  very  temporary  measure,  perhaps, 
to  insist  upon  a  recumbent  position  being  retained  for  any  length  of 
time.  Upon  this  point  Mr.  Teale  says  (and  he  says  all  that  need  be 
said),  "  When  my  attention  was  first  directed  to  this  subject,  I  con- 
sidered recumbency  a  necessary  part  of  the  treatment :  it  is,  for  a 
moderate  length  of  time,  undoubtedly  beneficial,  and  frequently  very 
much  accelerates  recovery ;  but  subsequent  observation  has  convinced 
me  that  it  is  by  no  means  essential.  I  have  seen  several  instances  of 
the  most  severe  forms  of  these  complaints,  occurring  in  the  poorer 
classes  of  society,  where  continued  recumbency  was  impracticable, 
which  have,  nevertheless,  yielded  without  difficulty  to  the  other  means 
of  the  treatment,  whilst  the  individuals  were  pursuing  their  laborious 
avocations." 

As  regards  diet  I  have  only  this  to  say — that  I  believe  the  great 
thing  to  be  done  is  to  supply  wine  or  some  other  alcoholic  drink  as 
well  as  nutritious  food  in  sufficient  quantity.  I  believe  that  nutritious 
food  in  itself  is  not  enough.  In  very  many  cases  it  it  found  that  alco- 
holic drinks  are  either  abstained  from  altogether  or  taken  in  very 
insignificant  quantities  from  a  fear  that  they  will  aggravate  the  pain 
or  spasm,  or  for  some  other  reason  :  in  very  many  cases  it  is  found  also 
that  relief  is  obtained  only  when  this  practice  is  abandoned,  and  the 
diet  made  to  include  at  least  an  average  share  of  the  drinks  in  question. 
Indeed,  the  result  of  my  own  experience  is  unequivocal  in  this  respect 
— that  the  somewhat  bold  use  of  alcoholic  drinks  is  a  cardinal  point 
in  the  treatment  of  spinal  irritation,  and  that  this  indication  must  be 
fully  acted  upon  if  this  treatment  is  to  lead  to  anything  like  satisfac- 
tory results. 

Of  the  spinal  maladies  remaining  to  be  noticed  the  principal  are 
these:  General  spinal  paralysis,  hysterical  paraplegia,  reflex  paraple- 
gia, infantile  paralysis,  hemorrhage,  non-inflammatory  softening,  indu- 
ration, atrophy,  hypertrophy,  tumour,  concussion,  compression,  caries 
of  the  vertebral  column,  spina  bifida,  &c. 


GENERAL    SPINAL    PARALYSIS.  71 


VI.  GENERAL  SPINAL  PARALYSIS. 

There  is  a  form  of  general  paralysis  to  which  Dr.  Calmeil  gave  the 
name  of  general  paralysis  of  the  insane,  and  with  which  all  who  know 
anything  of  insanity  are  sufficiently  familiar.  It  may  coexist  with 
any  form  of  insanity,  but  it  is  most  commonly  associated  with  the 
monomania  in  which  the  patient  believes  himself  to  be  possessed  of 
superhuman  power  and  unbounded  opulence.  The  first  signs  are 
likely  to  be  thickness  of  speech,  quivering  of  the  lips  and  tongue,  fum- 
bling and  clumsy  movements  of  the  fingers,  with  an  unsteady  and 
sidling  gait.  Then  the  urine  escapes  now  and  then  involuntarily,  or 
even  the  feces.  Once  begun,  the  downward  course  of  the  malady  is 
headlong,  and  in  a  few  months,  in  a  few  weeks  it  may  be,  within  two  or 
three  years  at  the  most,  the  patient  is  in  bed,  altogether  without  the 
power  of  supporting  himself  on  his  feet,  unable  to  use  his  hands  so  as 
to  help  himself  in  any  way,  incapable  even  of  turning  over  in  bed 
much  less  of  sitting  up,  requiring  to  be  fed  like  a  child,  and,  when  fed 
in  no  small  danger  of  choking  if  left  to  masticate  the  morsels,  with 
urine  and  feces  escaping  under  him  unheeded,  and  with  every  power 
of  body  and  mind  an  utter  wreck.  With  few  exceptions  the  thickness 
of  speech  shows  that  the  muscles  of  the  tongue  and  lips  are  the  first  to 
fail,  but  in  fact  all  parts  of  the  muscular  system  show  signs  of  weak- 
ness about  the  same  time,  and  it  is  difficult  to  fix  upon  any  one  part 
and  say  that  it  is  affected  before  the  rest.  Sometimes,  the  paralyzed 
muscles  become  considerably  atrophied,  but  the  rule  appears  to  be  that 
such  atrophy  is  less  marked  than  in  cases  where  the  paralysis  is  the 
result  of  disease  in  the  spinal  cord  :  always,  according  to  Dr.  Duchenne, 
the  paralyzed  muscles,  whether  atrophied  or  not,  retain  their  full  share 
of  electric  contractility.  After  death  signs  of  disease  are  found  in  the 
brain,  but  not  in  the  spinal  cord;  these  signs  being  increased  vascu- 
larity,  with  serous  or  sero-fibrinous  infiltration  in  the  pia  mater,  in 
the  cortical  substance,  and  in  the  brain  structure  generally. 

General  spinal  paralysis  is  the  name  used  by  Dr.  Duchenne  to  de- 
scribe a  form  of  paralysis  which,  until  he  pointed  out  the  differences, 
was  confounded  with  general  paralysis  of  the  insane.  Looking  hastily 
at  the  phenomena  of  paralysis  when  clearly  developed,  it  is,  indeed,  not 
to  be  wondered  at  that  these  two  disorders  should  have  been  confound- 
ed ;  but  in  reality  general  spinal  paralysis,  as  defined  by  Dr.  Duchenne, 
possesses  peculiarities  which  a*re  sufficiently  characteristic.  In  general 
spinal  paralysis  the  mental  faculties  are  natural ;  in  general  paralysis 
of  the  insane  they  are  fundamentally  deranged.  In  general  spinal 
paralysis  the  electric  contractility  of  the  paralyzed  muscles  is  abolished 
or  greatly  impaired  ;  in  general  paralysis  of  the  insane  it  is  intact.  In. 
general  spinal  paralysis  the  paralysis  usually  begins  in  the  legs  and 
travels  upwards,  often  remaining  in  the  lower  parts  of  the  body  a 
long  time  before  attacking  the  tongue,  face,  and  upper  extremities:  in 
general  paralysis  of  the  insane  all  parts  of  the  muscular  system  would 
seem  to  be  affected  simultaneously,  or,  if  there  be  any  difference  as  to 
time,  it  is  the  tongue  and  the  upper  parts  of  the  body  which  are  the 
first  to  suffer.  In  general  spinal  paralysis  there  is  a  marked  disposi- 


72  DISEASES    OF   THE    SPINAL    CORD. 

tion  to  atrophy  in  the  paralyzed  muscles  and  elsewhere,  to  bed-sores, 
and  to  other  signs  of  defective  nutrition  ;  in  general  paralysis  of  the 
insane  these  evidences  of  wasting  are,  to  say  the  least,  far  less  con- 
spicuous. In  general  spinal  paralysis  the  progress  of  the  disease  is  slow, 
often  extending  over  several  years;  in  general  paralysis  of  the  insane 
the  whole  course  of  the  disease  is  comprised  within  three  or  four  years 
at  most.  In  general  spinal  paralysis  the  post-mortem  signs  of  disease 
are  in  the  spinal  cord  and  not  in  the  brain ;  in  general  paralysis  of 
the  insane  the  reverse  of  this  obtains,  the  cord  being  healthy  and  the 
brain  the  seat  of  disease.  Much,  no  doubt,  remains  to  be  done  before 
it  is  possible  to  speak  positively  as  to  the  character  of  the  diseased 
changes  in  the  cord  which  are  met  with  in  general  spinal  paralysis ; 
and  at  present  it  must  suffice  to  say,  that  in  one  case  related  by  Dr. 
Duchenne  there  was  softening  and  injection  of  the  anterior  columns 
in  the  cervical  region  of  the  spinal  cord,  and  that  in  one  case  which  I 
had  the  opportunity  of  examining,  there  was  want  of  proper  consist- 
ence, not  exactly  amounting  to  actual  softening,  and  a  perceptible 
degree  of  atrophy,  in  these  columns  throughout  the  whole  of  their 
course  from  the  middle  of  the  neck  downwards.  Whether  general 
spinal  paralysis  will  prove  to  have  that  relation  to  disease  of  the  ante- 
rior columns  of  the  cord  which  locomotor  ataxy  has  to  disease  of  the 
posterior  columns,  remains  to  be  seen. 

General  spinal  paralysis  blends,  no  doubt,  with  other  spinal  diseases, 
and  its  symptoms  vary  accordingly;  but  still  it  occurs  with  sufficient 
frequency  in  the  form  described  by  Dr.  Duchenne  to  deserve  the 
position  which  he  assigns  to  it  as  an  individual  malady.  There  are 
also  relations  equally  intimate  between  general  spinal  paralysis  and 
cerebral  maladies,  and  I  am  very  much  disposed  to  think  that  the 
cases  in  which  the  mental  powers  are  obviously  weakened  will  be  found 
to  be  at  least  as  numerous  as  those  typical  cases  in  which  these  facul- 
ties are  natural.  At  the  same  time,  it  must  be  borne  in  mind  that  in 
some  oases  of  general  spinal  paralysis  the  mind  may  seem  to  be  weak- 
ened, when  in  reality  it  is  not  so — that  in  some  cases  there  may  be  an 
air  of  stupidity,  or  even  fatuity,  arising  from  the  slow  play  of  the  fea- 
tures, the  thickness  of  the  speech,  the  fumbling  of  the  fingers,  and  like 
symptoms,  which  air  has  its  origin  in  the  paralyzed  state  of  the  mus- 
cles and  not  in  the  enfeebled  state  of  "the  man  behind  the  mask." 

General  spinal  paralysis  cannot  be  confounded  with  local  Cruveilhier's 
atrophy,  or  lead  palsy,  and  it  must  not  Be  confounded  with  the  gene- 
ral forms  of  these  maladies.  In  general  Cruveilhier's  atrophy,  as  well 
as  in  local,  the  atrophy  of  the  muscles  is  partial,  certain  muscles  being, 
as  it  were,  dissected  out,  and  others  left  untouched,  capriciously ;  in 
general  spinal  paralysis  the  atrophy  is  en  masse.  In  general  Cruveil- 
hier's atrophy,  what  remains  of  muscle  obeys  the  will  and  reacts  with 
electricity  properly — there  is  no  paralysis ;  in  general  spinal  paralysis 
there  is  true  paralysis,  and  the  paralyzed  muscles  have  lost  their  elec- 
tric contractility.  In  general  lead  palsy,  also,  the  history  will  be 
sufficient  to  prevent  any  confusion  as  to  diagnosis — the  paralysis  at 
first  electing  the  extensor  muscles  of  the  forearm,  the  blue  line  upon 


HYSTERICAL    PARAPLEGIA.  73 

the  gums,  the  colic,  the  constipation,  the  possibility  of  lead  contami- 
nation, and  so  on. 

As  regards  treatment  there  is  nothing  to  be  said  except  that  it  must 
be  conducted  upon  the  same  principles  as  those  which  apply  in  analo- 
gous cases. 

VII.  HYSTERICAL  PARAPLEGIA. 

Paralysis  is  certainly  entitled  to  a  place  among  the  symptoms  of 
hysteria.  Dr.  Briquet  met  with  it  in  113  out  of  430  hysterical  patients, 
its  seat  being  in  the  four  extremities  and  in  the  principal  muscles  of 
the  trunk  in  6,  in  the  left  arm  and  leg  in  46,  in  the  right  arm  and  leg 
in  14,  in  both  arms  in  5,  in  the  left  arm  only  in  7,  in  the  right  arm 
only  in  2,  in  both  lower  limbs  in  18,  in  the  left  lower  limb  in  4,  in  the 
feet  and  hands  in  2,  in  the  face  in  6,  in  the  larynx  in  3,  in  the  dia- 
phragm in  2 ;  and  my  own  smaller  experience  is  more  in  harmony 
with  these  statistics  than  with  the  statement  of  Todd,  that  the  face 
and  tongue  escape  in  hysterical  paralysis,  that  the  hemiplegic  form  of 
paralysis  is  less  comrnwn  than  the  paraplegic,  arid  that  "  hysterical 
aphonia"  is  the  form  which  is  most  frequently  met  with. 

Hysterical  paralysis,  so  called,  is  generally  met  with  in  persons  of 
a  nervous  habit  of  body,  and  in  conjunction  with  symptoms  of  an  un- 
mistakably hysterical  character.  As  a  diagnostic  feature,  Todd  laid 
stress  on  a  peculiar  expression  of  countenance,  which  he  denominated 
fades  hysterica — an  expression  characterized  by  a  remarkable  depth 
and  prominent  fulness,  with  more  or  less  thickness,  of  the  upper  lip, 
and  by  a  peculiar  drooping  of  the  upper  eyelids,  and,  as  it  would  seem, 
with  good  reason.  Often,  moreover,  there  is  a  definite  history  of 
symptoms  which  clearly  come  within  the  category  of  hysterical  phe- 
nomena— emotional  excitability,  globus,  plentiful  gushes  of  pale  urine, 
and  the  rest.  In  diagnosing  hysterical  paralysis,  however,  it  is  not 
necessary  to  trust  solely,  or  even  chiefly,  to  evidence  such  as  this,  for 
the  paralysis  itself  is  found  to  have  certain  features  which  in  them- 
selves are  sufficiently  distinctive. 

Hysterical  paralysis  is  characterized  by  the  paralysis  being  more 
or  less  incomplete,  by  a  marked  degree  of  numbness  being  associated 
with  it,  and  chiefly  (according  to  Dr.  Duchenne)  by  the  paralyzed 
muscles,  which  are  not  wasted,  having  lost  their  electro-sensibility  with- 
out losing  their  electro -contractility — a  loss  which,  by  the  way,  does  not 
support  Sir  Benjamin  Brodie's  opinion  that  it  is  the  power  to  will 
contraction,  and  not  the  power  of  executing  the  orders  of  the  will, 
which  is  at  fault  in  this  form  of  paralysis. 

It  would  also  seem  to  be  a  peculiarity  of  hysterical  paralysis,  as  well 
as  of  hysterical  hypersesthesia,  anaesthesia  and  clonic  convulsion,  to 
affect  the  left  side  of  the  body  rather  than  the  right.  Thus,  M.  Briquet 
found  pleurodynia  nineteen  times,  hyperoesthesia  and  anaesthesia  five 
times,  cloriic  convulsion  twice,  and  paralysis  thrice  as  frequent  on  the 
left  side  as  on  the  right  side.  He  found,  indeed,  a  state  of  things 
which  presents  a  contrast  to  what  is  met  with  in  rheumatism,  neuralgia, 


7-i  DISEASES    OF    THE    SPIXAL    CORD. 

pleurisy,  pneumonia,  and  other  maladies,  in  all  of  which  it  is  the  right 
side  of  the  body  which  is  most  prone  to  suffer. 

Very  frequently,  I  believe,  hysterical  paralysis  is  preceded  by 
symptoms  which  come  under  the  head  of  spinal  irritation,  and  not 
un frequently,  especially  when  the  upper  part  of  the  body  is  affected, 
it  is  ushered  in  by  emotional  and  other  symptoms  which  may  at  times 
deserve  to  be  spoken  of  as  an  attack  of  hysteria. 

Hysterical  paraplegia  agrees  in  its  essential  features  with  other  forms 
of  hysterical  paralysis.  The  paralysis  is  usually  incomplete.  Numb- 
ness of  the  paralyzed  parts  is  a  conspicuous  phenomenon;  as  conspi- 
cuous, it  may  be,  as  the  paralysis.  The  paralyzed  muscles  have  lost 
their  electro-sensibility  without  losing  their  electro-contractility.  The 
bladder  and  bowel  (as  much  apparently  for  want  of  proper  sensibility 
as  from  true  paralysis)  are  little  under  control,  if  at  all;  less  so,  as  a 
rule,  than  in  common  paraplegia.  The  paralysis  is  often  preceded  by 
symptoms  of  spinal  irritation,  in  the  lumbar  region  especially — spinal 
tenderness,  pains  about  the  pelvis  and  in  the  legs,  irritability  of  the 
bladder,  and  the  rest;  and  now  and  then  it  is  ushered  in  by  some 
ordinary  hysterical  disturbance  of  one  kind  or  other.  And  where  one 
leg  only  is  affected,  there  would  seem  to  be,  as  Todd  pointed  out,  a 
gait  which  is  not  less  characteristic  than  that  which  is  seen  in  common 
hemiplegia.  In  common  hemiplegia  the  trunk  in  walking  is  first  of 
all  inclined  to  the  sound  side,  and  the  whole  weight  of  the  body  made 
to  rest  upon  the  sound  leg,  and  then  the  paralyzed  limb  is  raised  from 
the  ground  and  thrown  forwards  by  swinging  it  outwardly ;  the  whole 
series  of  movements  being  very  like  those  which  are  necessary  in 
walking  with  a  wooden  leg.  In  hysterical  paralysis,  where  one  leg 
only  is  affected,  the  paralyzed  limb,  instead  of  being  raised  from  the 
ground,  as  in  common  hemiplegia,  and  thrown  forward  by  an  outward 
swing,  is  dragged  directly  forward,  with  the  foot  trailing  on  the  ground. 

The  prognosis  in  hysterical  paralysis  would  always  seem  to  be  fa- 
vourable. Sooner  or  later,  in  one  way  or  another,  a  cure  is  brought 
about,  most  tardily ;  perhaps,  in  the  paraplegic  form  of  the  disorder. 

As  regards  treatment,  all  that  need  be  said  is,  that  general  rules 
must  be  followed  out,  and  that,  if  anything  special  has  to  be  done, 
most  help  will  probably  be  derived  from  sharp  faradization  with  elec- 
trodes which  allow  the  currents  to  act  on  the  sentient  nerves  rather 
than  on  the  muscles — that  is,  with  metal  ends  rather  than  with  the 
•moistened  sponges  commonly  used.  At  any  rate,  sharp  practice  of 
this  kind  has  often  served  to  bring  about  results  as  sudden  and  satis- 
factory as  those  which  have  now  and  then  followed  the  exercise  of 
faith  in  the  power  of  St.  MeMard  and  other  kindred  agencies. 

VIII. — REFLEX  PARAPLEGIA. 

Paraplegia  is  one  of  the  consequences  of  primary  disease  in  the  spi- 
nal cord  :  of  this  there  can  be  no  doubt.  Paraplegia  may  also  be  the 
result  of  disorder  or  disease  beginning  at  a  distance  and  affecting  the 
cord  secondarily — beginning  in  the  urinary  and  genital  organs  more 
especially :  of  this  there  can  be  but  little  doubt.  In  the  former  case 


REFLEX    PARAPLEGIA.  75 

the  paraplegia  is  spoken  of  as  centric;  in  the  latter  as  eccentric  or 
reflex. 

The  chief  characteristics  of  that  form  of  reflex  paraplegia  which  is 
associated  with  disease  of  the  urinary  organs — urinary  paraplegia,  as  it 
is  often  called — the  commonest  and  most  important  of  all  the  forms  of 
reflex  paraplegia,  as  it  certainly  is,  are  these;  or  at  any  rate  these  are 
those  upon  which  Dr.  Brown-Sequard,  who  has  paid  much  attention 
to  this  subject,  insists.  Usually  the  paralysis  is  incomplete  both  as  to 
degree  and  extent,  some  muscles  being  obviously  more  affected  by  it 
than  others.  Usually  the  paralysis  is  not  associated  either  with  ti  ngling, 
or  numbness,  or  anaesthesia.  Usually  the  bladder  and  rectum  are  only 
slightly  implicated  in  the  paralysis.  Usually  there  are  changes  for 
the  better  or  the  worse  in  the  degree  of  paralysis  corresponding  to 
changes  for  the  better  or  worse  in  the  disease  of  the  urinary  organs. 
Usually  there  is  no  marked  atrophy  in  the  paralyzed  muscles.  Not 
unfrequently  a  cure  or  marked  amelioration  in  the  paralytic  condition 
is  brought  about  by  the  removal  of  the  disease  in  the  urinary  organs. 
Dr.  Brown-Sequard  indicates  these  as  the  chief  characteristics  of  reflex 
paraplegia  connected  with  disease  of  the  urinary  organs,  and  of  other 
forms  of  reflex  paraplegia  as  well,  the  only  difference  in  the  descrip- 
tion of  these  latter  forms  of  disease  being  the  substitution  for  the  term, 
urinary  of  the  name  which  indicates  the  starting- point  for  the  paraly- 
sis. 

Thus  de6ned,  reflex  paraplegia  differs  diametrically  from  the  para- 
plegia produced  by  myelitis.  In  paraplegia  from  myelitis  the  paralysis 
is  usually  complete,  and  all  the  muscles  are  affected  equally :  not  so 
in  reflex  paraplegia.  In  paraplegia  from  myelitis  the  paralysis  is 
associated  with  tingling,  numbness,  or  anaesthesia:  not  so  in  reflex  para- 
plegia. In  paraplegia  from  myelitis  paralysis  of  the  bladder  and  lower 
bowel  is  a  marked  phenomenon :  not  so  in  reflex  paraplegia.  In 
paraplegia  from  myelitis  the  paralyzed  muscles  are  usually  atrophied 
and  degenerated :  not  so  in  reflex  paraplegia.  In  paraplegia  from 
myelitis  cure,  or  even  improvement,  is  the  exception :  in  reflex  para- 
plegia it  is  the  rule. 

It  is,  indeed,  easy  enough  to  find  marked  differences  between  para- 
plegia from  myelitis  and  reflex  paraplegia :  but  the  case  is  far  other- 
wise when  a  comparison  is  instituted  between  paraplegia  from  spinal 
congestion  and  reflex  paraplegia.  In  reflex  paraplegia  the  paralysis 
is  incomplete,  and  all  muscles  are  not  affected  equally:  in  paraplegia 
from  spinal  congestion  it  is  so  also.  In  reflex  paraplegia  the  paralysis 
is  not  associated  with  tingling,  numbness,  or  anaesthesia :  in  paraplegia 
from  spinal  congestion  it  is  the  same,  with  the  single  exception,  that 
there  may  be  at  one  time  or  other  a  trifling  degree  of  tingling  at  the 
extreme  tips  of  the  fingers  or  toes.  In  reflex  paraplegia  there  are 
fluctuations  in  the  degree  of  the  paralysis:  so  also  in  paraplegia  from 
spinal  congestion.  In  reflex  paraplegia  there  is  no  marked  change  in 
the  nutrition  of  the  muscles :  so  also  in  paralysis  from  spinal  congestion. 
And,  lastly,  in  reflex  paraplegia,  as  in  paraplegia  from  spinal  conges- 
tion, a  cure  is  neither  an  impossible,  nor  even  an  improbable  event. 
As  to  essential  characteristics,  indeed,  I  can  find  marked  differences 


76  DISEASES    OF    THE    SPINAL    COED. 

when  reflex  paraplegia  is  compared  with  paraplegia  from  myelitis; 
but  none  when  reflex  paraplegia  is  put  in  comparison  with  paraplegia 
from  spinal  congestion. 

Nor  is  reflex  paraplegia  always  to  be  distinguished  by  being  obvi- 
ously preceded  by  eccentric  disorder  in  the  urinary  organs  or  elsewhere. 
It  is,  indeed,  as  Dr.  Gull  has  well  pointed  out,  "not  always  easy  to 
determine  at  this  point  whether  symptoms  have  a  central  or  a  peripheral 
origin  ....  There  is,  perhaps,  no  fact  to  be  more  insisted  upon  than 
the  normal  dependence  of  the  sympathetic  upon  the  integrity  of  the  spi- 
nal system.  As  a  result  of  this  dependence  we  learn  that  dyspepsia, 
vomiting,  constipation,  colic,  vesical  catarrh,  prostatic  irritation,  pains 
in  the  joints,  and  many  other  peripheral  disturbances,  may  seem  to 
precede  the  central  malady,  and  to  be  the  cause  of  it,  when  in  truth 
they  are  its  effects."  And  again  :  "  It  is  no  new  fact  in  medicine,  that 
cerebral  exhaustion  may  impair  the  functions  of  the  cord  (especially 
of  the  lower  segments),  and  give  rise  to  precisely  those  symptoms 
which  have  been  set  down  as  pathognomonic  of  urinary  paraplegia." 

Dr.  Brown-Se'quard  has  taken  a  very  different  view  of  reflex  para- 
plegia to  that  which  is  here  taken.  He  regards  this  disorder  as  due, 
not  to  spinal  congestion,  but  to  a  state  of  the  circulation  diametrically 
opposed  to  this.  He  believes  that  a  state  of  irritation,  commencing 
eccentrically,  is  propagated  along  the  vaso-motor  nerves,  of  which  the 
result  is,  primarily,  contraction  of  bloodvessels  in,  and  secondarily, 
exclusion  of  the  due  amount  of  blood  from,  one  or  more  of  the  three 
parts  following — the  spinal  cord,  the  nerves  proceeding  to  or  coming 
from  the  cord,  the  muscles.  He  believes  that  the  proper  activily  of 
the  nervous  tissue  or  muscle  is  starved  into  paralysis  for  want  of  blood ; 
and  he  founds  this  view  on  the  fact  that  a  state  of  irritation  in  the 
vaso-motor  nerves  may  proceed  from  a  distant  point  and  produce  con- 
fraction  of  the  vessels,  and  upon  the  fact  that  traces  of  organic  disease 
are  wanting  after  death  in  many  cases  of  reflex  paraplegia.  The 
argument,  indeed,  is  all  but  as  conclusive  as  it  is  masterly  and  original. 
The  same  evidence,  however,  admits  of  a  very  different  construction, 
and  that  even  without  anything  like  special  pleading.  It  is,  no  doubt, 
true  enough  that  a  state  of  irritation  in  vaso-motor  nerves  may  lead 
to  contraction  in  bloodvessels  and  thereby  exclude  a  due  amount  of 
blood  from  the  part  to  which  these  vessels  belong ;  but  it  is  not  less 
certain  that  the  same  state  of  irritation  carried  beyond  a  given  degree, 
either  in  time  or  in  intensity,  may,  by  paralyzing  the  vaso-motor  nerves, 
lead  to  relaxation  of  vessels,  and,  thereby,  to  the  admission  into  them 
of  an  undue  amount  of  blood.  Moreover,  it  may  also  be  assumed,  as 
a  thing  by  no  means  improbable,  that  the  contraction  of  the  coats  of 
the  relaxed  and  paralyzed  vessels  in  rigor  mortis  may  prevent  any 
marked  traces  of  such  vascular  engorgement  being  met  with  after 
death  ;  at  any  rate  it  is  impossible  to  infer  from  the  absence  of  such 
traces  of  congestion  after  death,  that  there  was  no  such  congestion 
during  life.  Indeed,  the  evidence  adduced  by  Dr.  Brown-S^quard 
in  favour  of  his  theory  of  reflex  paraplegia  is  in  itself  insufficient 
to  decide  whether  his  view  or  that  which  I  venture  to  put  in  op- 
position to  it  is  the  correct  one,  for  in  reality  it  may  be  used  equally 


KEFLEX    PARAPLEGIA.  f  77 

in  support  of  either  view.  And  certainly  it  would  seem  to  be  a 
collateral  objection  to  the  view  which  connects  reflex  paraplegia  with 
a  state  of  capillary  contraction  and  comparative  bloodlessness  brought 
about  by  irritation  in  vaso-motor  nerves,  that  in  states  where  the  whole 
nervous  system  is  in  a  state  of  great  irritation,  as  in  tetanus,  and  in 
the  state  specifically  designated  spinal  irritation,  and  where  it  may 
be  assumed  that  the  vaso-motor  nerves  participate  in  this  state  of  irri- 
tation, and  produce  vascular  contraction  and  comparative  bloodlessness 
in  the  spinal  cord  and  elsewhere,  that  paraplegia  or  any  form  of  paralysis 
is  precisely  the  symptom  which  is  not  present.  Moreover,  Dr.  Gull 
makes  some  remarks  on  urinary  paraplegia  which  have  an  important 
collateral  bearing  on  the  subject  in  hand,  and  which  tend  in  no  ordinary 
degree  to  support  the  conclusion  to  which  all  the  previous  considera- 
tions tend  :  "If,"  he  says,  "  we  regard  the  nature  of  the  urinary  disea.se 
which  most  commonly  leads  to  paraplegia,  we  shall  find  that  it  is  an 
inflammation,  either  in  the  prostate,  bladder,  or  kidneys;  and  we  shall 
also  find,  that  it  is  only  after  chronic  inflammation  has  lasted  a  long 
time  that  the  paraplegic  weakness  supervenes.  It  is  in  just  those  cases 
where  there  is  most  irritation,  and  but  little  inflammation,  that  para- 
plegia does  not  occur.  Uric  acid  and  oxalate  of  lime  calculi  may 
cause  ha^maturia  and  any  amount  of  irritation,  but  unless  suppurative 
inflammation  set  in,  paraplegia  is  not  produced.  A  review  of  all  the 
recorded  cases  of  urinary  paraplegia  will  show  that  it  is  the  inflamma- 
•tory  condition  of  the  urinary  organs  which  leads  to  paralysis,  and  not 
one  of  irritation." 

In  speaking  in  this  manner,  however,  I  do  not  wish  to  confound 
reflex  paraplegia  with  spinal  congestion.  On  the  contrary,  the  more 
I  see  of  practice  the  more  I  am  disposed  to  think  that  there  is  a  reflex 
variety,  not  only  in  paraplegia  from  spinal  congestion,  but  in  every 
form  of  paraplegia;  that,  in  fact,  the  causes  at  work  in  producing  all 
spinal  maladies  are  reflex  in  their  character  as  well  as  centric,  reflex, 
it  may  be,  rather  than  centric. 

If  the  true  view  of  reflex  paraplegia  be  the  one  which  is  here  taken, 
it  follows  that  the  treatment  of  that  form  of  this  disorder  which  is 
defined  by  Dr.  Brown-Se'quard  will  be  substantially  the  same  as  the 
treatment  of  paraplegia  from  spinal  congestion,  and  not  that  which  has 
been  recommended  on  the  supposition  that  the  spinal  cord  is  starved 
for  want  of  blood  in  consequence  of  its  vessels  being  kept  in  a  state 
of  contraction  by  irritation  of  the  vaso-motor  nerves.  Nay,  even  the 
necessity  to  treat  eccentric  disorder  or  disease  in  the  urinary  organs  or 
elsewhere  can  scarcely  be  considered  a  peculiar  feature  in  the  treat- 
ment of  reflex  paraplegia;  for,  in  fact,  it  is  always  an  essential  part  of 
any  sound  plan  of  treatment  in  any  disease  of  the  spinal  cord,  whether 
originating  in  the  cord  or  at  a  distance  from  the  cord,  to  make  a  point 
of  doing  everything  to  remove  or  mitigate  any  eccentric  malady.  It 
is  always  necessary  to  do  this,  because  an  eccentric  malady,  whether 
primary  or  secondary  to  the  spinal  disorder,  or  whether  having  no 
other  than  a  purely  accidental  relation  to  this  disorder,  invariably 
reacts  prejudicially  upon  the  cord.  This  eccentric  malady  must  of 
course  be  dealt  with  on  general  principles,  this  thing  or  that  being 


78  DISEASES    OF    THE    SPINAL    CORD. 


c 


done  according  as  irritation  or  inflammation  may  happen  to  be  the 
predominating  condition.  In  urinary  paraplegia,  for  example,  it  is 
very  possible  that  the  local  application  of  opium,  or  belladonna  to  the 
urethra,  as  recommended  by  Dr.  Brown-Sequard,  may  be  of  much 
use;  this  is  very  possible  on  any  hypothesis:  but  with  respect  to  the 
frequent  introduction  of  catheters,  with  a  view  to  relieve  irritation,  I 
think  it  is  difficult  to  come  to  a  different  conclusion  to  that  which  Dr. 
Gull  has  arrived  at.  "This  course,"  says  this  able  physician,  "is  not 
unattended  with  danger.  There  is  no  part  of  the  treatment  which 
calls  for  more  discrimination.  The  diseased  textures  and  veins  about 
the  neck  of  the  bladder  are  so  prone  to  suppuration,  that  the  catheter 
is  often  a  fatal  weapon.  The  few  scattered  instances,  such  as  that 
recorded  by  Dr.  Graves,  where  immediate  good  effects  have  followed, 
have  had  undue  influence  towards  promoting  mechanical  interference. 
Carefully  considered,  they  do  not  warrant  the  inference  drawn  from 
them.  If  the  urinary  passages  are  so  contracted  that  the  bladder 
cannot  empty  itself,  the  catheter  is  obviously  required  ;  but  it  must  be 
simply  prescribed  on  these  grounds.  The  rule  for  its  use  is  the  same 
as  in  the  treatment  of  the  aural  passages,  when  the  middle  ear  is  dis- 
eased. If  there  be  a  free  exit  for  the  excretions,  the  less  mechanical 
interference  the  better.  As  meddlesome  midwifery  is  bad,  so  is  the 
meddlesome  employment  of  the  catheter  in  urinary  paraplegia.  Cases 
might  be  quoted  where  a  fatal  issue  has  been  induced  by  the  meddle- 
some interference  with  a  diseased  bladder,  under  the  houe  of  removing 
some  hypothetical  cause  of  reflex  irritation." 

IX. — INFANTILE  PARALYSIS. 

This  disorder,  to  which  attention  seems  to  have  been  directed  first  of 
all  by  Underwood,  Marshall  Hall,  and  Kennedy,  is  the  paralysie  (dite 
essenlielle)  de  Venfance  of  several  French  writers.  It  attacks  children 
indiscriminately,  without  any  regard  to  sex,  between  the  age  of  six 
months  and  two  years,  at  the  time  of  the  first  dentition  more  especially ; 
and  it  is  the  grand  source  of  shrivelled,  half-dead  limbs,  club-feet,  and 
other  sad  deformities. 

Mr.  William  Adams,  who  has  had  ample  opportunities  of  becoming 
practically  acquainted  with  the  history  of  infantile  paralysis,  and  whose 
account  of  this  disorder  is  more  to  the  point  than  any  other  with 
which  I  am  acquainted,  indicates  these  as  the  most  trustworthy  charac- 
teristics: 1.  The  paralysis  is  usually  partial,  single  muscles  or  groups 
of  muscles  only  being  affected.  2.  The  sensation  in  the  paralyzed  parts 
is  usually  perfect,  or  all  but  perfect.  3.  The  bladder  and  lower  bowel 
are  usually  not  distinctly  implicated  in  the  paralysis.  4.  The  para"- 
lyzed  muscles  are  at  no  time  rigid.  5.  Great  improvement  or  complete 
recovery  is  the  rule,  and  not  the  exception.  The  paralysis  is  usually 
neither  accompanied  nor  preceded  by  "  head  symptoms." 

The  onset  of  the  disorder  is  generally  sudden  and  unexpected.  The 
child  is  put  to  bed  well,  and  in  the  morning  it  is  found  to  be  paralyzed. 
Or  the  paralysis  may  be  grafted  upon  some  marked  febrile  disorder,  as 
gastric  or  remittent  fever,  measles,  or  typhus;  or  upon  some  other 


INFANTILE    PARALYSIS.  79 

malady,  as  hooping-cough  and  pneumonia.  In  some  cases  there  may 
be  transitory  and  trifling  feverishness  at  first,  but  fever  is  certainly  no 
essential  accompaniment  at  any  time.  Now  and  then,  but  only  in 
exceptional  cases,  the  disorder  may  be  ushered  in  by  convulsions  or 
drowsiness. 

The  paralysis  has  usually  a  wider  range  at  first  than  that  which  it 
takes  afterwards;  in  other  words,  the  paralysis  is  more  or  less  general 
at  first,  and  more  or  less  localized  afterwards.  Thus  it  is  a  common 
thing  for  all  the  limbs  to  be  attacked  and  for  only  one  leg  to  remain 
paralyzed,  or,  rather,  to  remain  partially  paralyzed,  for  there  is  a  cer- 
tain degree  of  recovery  in  certain  muscles,  even  in  the  worst  cases.  It 
is  the  constant  rule,  indeed,  for  recovery  to  be  slower  in  the  legs  than 
in  the  arms,  and  in  certain  muscles  than  in  others.  Usually  the  disease 
does  not  mount  high  enough  to  paralyze  muscles  whose  nerves  are 
given  off  above  the  true  limits  of  the  spinal  cord.  There  is  certainly 
no  loss  of  sensation  in  infantile  paralysis.  On  the  contrary,  as  Dr. 
West  remarks  in  his  admirable  treatise  on  the  diseases  of  infancy  and 
childhood,  "sensation  in  the  affected  limb  appears  to  be  exalted  when 
the  paralysis  is  recent,  the  degree  of  hyperassthesia  in  the  early  stage 
being  in  such  cases  proportionate  to  the  loss  of  power  which  afterwards 
is  apparent."  Moreover  Dr.  West  proceeds  to  say,  "In  some  instances 
the  exaggerated  sensibility  continues  for  several  weeks,  though  this  is 
unusual ;  and  when  this  is  the  case,  the  leg  being  the  seat  of  the  affec- 
tion, and  the  paralysis  incomplete,  the  existence  of  hip-joint  disease 
may  very  likely  be  suspected.  In  such  a  case  the  child  bears  all  its 
weight  on  the  healthy  limb,  turns  the  foot  of  the  affected  side  inwards 
when  walking,  and  stands  with  the  toes  of  that  foot  resting  on  the 
dorsum  of  the  foot  of  the  healthy  side.  Still  it  will  usually  be  found 
that  the  exaggerated  sensibility  of  the  paralyzed  limb  varies  greatly 
at  different  times,  while  that  extreme  increase  of  suffering  produced  in 
cases  of  hip-joint  disease  on  striking  the  head  of  the  femur  against  the 
acetabulum  by  a  blow  upon  the  heel,  and  the  fixed  pain  in  the  knee 
of  the  affected  side,  so  characteristic  of  diseases  of  the  hip-joint,  are 
absent;  and  these  points  of  difference  will  enable  you  to  distinguish 
between  the  two  affections.  One  other  important  means  of  diagnosis 
is  furnished  by  the  presence  or  absence  of  an  increased  temperature 
over  the  suspected  joint,  the  value  of  which  easy  observation  in  deter- 
mining the  presence  or  absence  of  inflammation  about  any  particular 
spot  is  dwelt  upon  by  Mr.  Hilton  in  his  lectures  delivered  recently  at 
the  College  of  Surgeons." 

The  peculiarities  of  infantile  paralysis,  so  thinks  Mr.  Adams,  point 
to  a  special  pathology  which  has  yet  to  be  made  out  satisfactorily. 
As  it  seems  to  me,  however,  these  peculiarities,  instead  of  showing,  as 
Mr.  Adams  believes,  that  infantile  paralysis  is  unlike  paralysis  in  adults, 
only  show  a  close  analogy  to,  if  not  an  actual  identity  with,  the  para- 
lysis which  has  been  seen  to  result  from  spinal  congestion.  In  infantile 
paralysis  the  paralysis  is  partial :  in  paralysis  from  spinal  congestion 
it  is  the  same.  In  infantile  paralysis  sensation  is  exaggerated  rather 
than  dulled  in  the  paralyzed  parts :  in  paralysis  from  spinal  congestion 
it  is  the  same.  In  infantile  paralysis  the  bladder  and  lower  bowel  are 


80  DISEASES    OF    THE   SPINAL    CORD. 

obedient  to  the  will :  so  also  in  paralysis  from  spinal  congestion.  In 
infantile  paralysis  the  paralyzed  muscles  are  limber,  not  rigid :  so  also 
in  paralysis  from  spinal  congestion.  In  infantile  paralysis  recovery 
more  or  less  complete  is  the  rule  rather  than  the  exception  ;  so  also, 
and  very  much  in  the  same  order,  in  paralysis  from  spinal  congestion. 
In  infantile  paralysis  "  head  symptoms"  are  exceptional  phenomena  at 
any  time:  so  also  in  the  paralysis  from  spinal  congestion.  Neither 
do  I  know  of  anything  to  invalidate  the  conclusion  which  those  resem- 
blances would  seem  almost  to  necessitate — that  infantile  paralysis,  as 
defined  by  Mr.  Adams,  is  nothing  more  than  paralysis  from  spinal 
congestion. 

Moreover,  this  conclusion  is  not  discredited  by  the  disclosures  of 
morbid  anatomy.  There  were  no  traces  of  organic  disease  either  in 
the  spinal  cord  or  brain  or  nerves  in  the  four  cases  of  genuine  infan- 
tile paralysis  which  were  examined  after  death  by  MM.  Barthez  and 
Eilliet,  Dr.  Fliess,  and  Mr.  Adams,  all  four  most  competent  observers. 
The  evidence  supplied  by  these  cases  is  indeed  purely  negative.  Nor 
is  evidence  more  positive  to  be  found  in  the  two  cases  examined  after 
death  by  M.  Laborde,  the  writer  of  a  very  able  treatise  on  infantile 
paralysis  recently  published.  In  these  two  cases,  without  doubt,  there 
were  certain  organic  changes  in  the  spinal  cord  and  in  some  of  its 
nerves,  but  these  changes  are  plainly  not  essential  to  infantile  para- 
lysis as  defined  alike  by  M.  Laborde  and  Mr.  Adams,  for  the  simple 
fact  is,  that  the  clinical  history  of  these  cases  is  not  clearly  that  of  in- 
fantile paralysis  so  defined.  In  a  word,  there  is  nothing  in  the  scanty 
contributions  of  the  dead-house  to  show  that  the  very  closest  relations 
may  not  exist  between  the  disorder  under  consideration  and  spinal 
congestion. 

The  duration  of  infantile  paralysis  is  very  variable.  It  may  pass  off 
in  a  few  days,  or  even  a  few  hours :  it  is  more  likely  to  occupy  several 
weeks  or  months  in  this  process  of  improvement.  Improvement,  to  a 
greater  or  less  degree,  is  indeed  the  rule,  and  not  the  exception  ;  and 
it  may  even  be  said  that  the  cases  which  stop  far  short  of  recovery  are 
by  no  means  common.  Mr.  Adams  says,  "It  is  generally  supposed 
that,  unless  recovery  takes  place  within  a  few  months,  the  paralysis  is 
persistent  through  life;  but  I  have  seen  many  cases  in  which  improve- 
ment has  proceeded,  to  a  very  useful  extent,  several  years  after  the 
seizure;"  and  to  the  truth  of  this  remark  my  own  experience  bears 
ample  testimony.  Indeed,  I  should  say  from  what  I  have  seen,  that 
if  the  paralyzed  muscles  retain  their  electro-contractility  and  electro- 
sensibility,  and  so  show  that  they  have  not  passed  into  that  state  of 
fatty  degeneration  into  which  they  always  tend  to  pass  eventually, 
there  appears  to  be  scarcely  any  limit  to  the  time  in  which  improve- 
ment, and  even  complete  recovery,  is  possible. 

The  groups  of  muscles  most  frequently  affected  in  infantile  paralysis, 
according  to  Mr.  Adams,  are,  1.  The  muscles  of  the  anterior  part  of  the 
leg,  forming  the  extensors  of  the  toes  and  the  flexors  of  the  foot ;  2. 
The  extensors  and  supinators  of  the  hand,  these  muscles  being  always 
affected  together ;  and  3.  The  extensors  of  the  leg,  and  with  them 
generally  the  muscles  of  the  foot,  as  in  the  first  group.  When  single 


INFANTILE    PARALYSIS.  81 

muscles  are  affected,  the  most  likely  to  suffer  are  these:  1.  The  ex- 
tensor longus  digitorum  of  the  toes ;  2.  The  tibialis  anticus ;  3.  The 
deltoid;  and  4.  The  sterno-mastoid. 

The  deformities  produced  by  infantile  paralysis  are  most  frequently 
met  with  in  the  feet  and  legs,  because  these  are  the  parts  most  fre- 
quently affected ;  and  the  particular  kind  of  deformity  varies,  of  course, 
with  the  muscles  involved  in  the  paralysis. 

"The  most  frequent  kind,"  says  Mr.  Adams,  "is  that  of  (1)  talipes 
equinus;  and  the  other  deformities  occur  in  the  following  order — (2) 
equino-varus;  (3)  equiuo-valgus;  (4)  calcaneus,  or  calcaneo-valgus ; 
and  (5)  talipes  varus.  When  both  feet  are  affected,  equino-varus  of 
one  foot  is  generally  found  with  equino-valgus  of  the  other." 

Mr.  Adams  is  of  opinion  that  the  great  cause  of  the  deformities 
which  are  met  with  in  infantile  paralysis  is  the  "  adapted  atrophy"  of 
Mr.  Paget,  this  change  taking  place  chiefly  in  the  opponents  of  the 
muscles  which  have  suffered  from  paralysis.  If,  for  example,  the 
anterior  muscles  of  the  leg  are  paralyzed,  the  anterior  portion  of  the 
foot  drops,  and  the  heel  is  raised,  not  by  active  contraction  of  the 
posterior  muscles — for  division  or  paralysis  of  one  set  of  muscles  does 
not  excite  active  contraction  in  the  opponent  muscles — but  in  conse- 
quence of  the  position  assumed  by  the  foot  from  its  mechanical  relations 
with  the  leg.  Another  cause  of  deformity  is  obviously  atrophy  and 
actual  or  comparative  arrest  of  development  in  the  paralyzed  muscles ; 
for,  unless  the  paralysis  soon  passes  off,  it  is  plain  that  the  muscles 
will  not  only  waste,  but  be  left  behind  in  the  rapid  process  of  develop- 
ment which  is  everywhere  at  work  in  a  young  and  growing  child. 
Mr.  Adams  is  also  of  opinion  that  the  early  and  late  rigidity  of  Todd 
and  true  spasm  have  very  little  to  do  in  causing  the  deformities  in 
question :  and  so  it  may  be  in  the  deformities  connected  with  that  form 
of  paralysis  to  which  he  restricts  the  term  infantile — that  form  which 
is  undoubtedly  the  common  variety  of  infantile  paralysis,  and  which, 
as  it  would  seem,  is  dependent  on  spinal  congestion.  It  is  very  cer- 
tain, however,  that  infants  and  children  are  liable  to  more  than  one 
form  of  paralysis,  and  that  there  are  deformities  associated  with  rigid 
as  well  as  with  flaccid  muscles.  It  is  very  certain  that  this  rigidity 
may  be  either  "early"  or  "late,"  as  distinguished  by  Todd,  or  even 
still  more  decidedly  spasmodic  than  that  form  which  is  called  "early 
rigidity."  In  a  word,  infantile  paralysis  is  a  designation  as  little  to 
be  defended  as  would  be  the  term  adult  paralysis;  for  on  inquiry  it 
is  found  that  in  children,  as  in  adults,  there  is  more  than  one  form  of 
paralysis,  and  that  all  the  forms  which  may  happen  in  adults  may  be 
repeated  in  children.  The  form  of  paralysis  which  has  been  described 
as  infantile  is  unquestionably  the  commonest,  and  the  other  forms  are 
so  uncommon  as  to  be  little  more  than  exceptional ;  and  this,  in  fact, 
is  all  that  can  be  said  to  justify  the  notion  that  infantile  paralysis  is  a 
definite  disorder  of  the  spinal  cord  peculiar  to  infants. 

The  treatment  of  the  deformities,  especially  of  club-foot,  resulting 

from  the  so-called  infantile  paralysis,  is  a  subject  of  much  practical 

interest  and  difficulty.     Mr.  Adams  says :  "  The  probability  of  benefit 

in  such  cases  by  any  surgical  procedure  seems  scarcely  ever  to  be 

6 


82  DISEASES    OF    THE    SPINAL    CORD. 

entertained.  The  existence  of  paralysis  is  supposed  to  contraindicate 
any  surgical  interference ;  but,  from  these  apparently  hopeless  and 
essentially  incurable  cases  some  of  the  most  striking  and  most  valuable 
results  of  surgery  are  obtained  by  a  combination  of  surgical  and 
mechanical  treatment.  Mechanical  aid,  alone,  is  frequently  sought 
from  the  instrument-maker,  but  his  art  is  powerless  when  any  con- 
siderable amount  of  deformity  exists ;  and  it  is  only  by  a  scientific 
combination  of  surgical  and  mechanical  skill  that  much  good  can  be 
effected.  In  all  these  cases  the  treatment  essentially  consists  in  the 
removal  of  existing  deformities  by  tenotomy  and  mechanical  means, 
and  a  subsequent  compensation  for  the  existing  paralysis  by  mechan- 
ical support,  varying  in  different  cases  according  to  the  extent  of  the 
paralysis."  And  no  doubt  very  satisfactory  results  are  obtained  by 
those  means.  At  the  same  time  it  is  certain  that  in  many  cases  very 
satisfactory  results  may  be  obtained  without  tenotomy,  and  without 
apparatus,  by  means  used  with  the  view  of  bringing  back  power  into 
the  paralyzed  muscles — electricity,1  movements  of  various  kinds, 
shampooings,  and  others;  and  my  own  experience  has  convinced  me 
that  this  fact  is  not  yet  sufficiently  recognized  and  acted  upon  in 
practice.  That  in  many  cases  neither  tenotomy  nor  apparatus  can  be 
dispensed  with  I  fully  believe:  that  in  all  cases  the  electrical  and 
gymnastical  parts  of  the  treatment  are  of  primary  rather  than  of  merely 
secondary  importance  I  am  every  day  more  and  more  convinced,  be- 
cause every  day  I  meet  with  instances  of  muscles  which  I  should  once 
have  looked  upon  as  hopelessly  paralyzed  being  resuscitated  by  those 
means.  Indeed,  I  cannot  but  think  that  so  long  as  institutions  specially 
set  apart  for  orthopedic  purposes  are  wanting  in  properly  furnished 
electrical  rooms  and  gymnasiums,  there  must  be  in  some  essential 
points  a  necessity  for  a  great  reformation  in  orthopedic  practice. 

X. — HEMOREHAGE. 

Blood  may  be  effused  into  the  substance  of  the  cord  between  the 
arachnoid  and  pia  mater,  into  the  sac  of  the  arachnoid,  between  the 
dura  mater  and  arachnoid,  or  between  the  dura  mater  and  the  osseous 
canal — anywhere  in  or  about  the  spinal  cord,  in  fact.  Hemorrhage 
in  the  substance  of  the  cord,  the  hcematomyelie  of  Ollivier,  may  be  a 
consequence  of  myelitis,  the  bloodvessels  breaking  up  in  the  soften- 
ing of  the  cord,  and  so  allowing  the  blood  to  escape.  It  was  so  in  the 
acute  case  which  I  took  as  my  text  when  speaking  of  myelitis,  for 

1  There  are  certain  forms  of  paralysis  in  which  the  paralyzed  muscles  do  not  react 
to  the  most  powerful  induced  electric  currents,  but  react  energetically  to  a  galvanic 
current  of  low  tension,  slowly  interrupted  (the  labile  current  of  Remak).  The  diag- 
nostic and  therapeutic  bearings  of  this  fact  have  yet  to  be  worked  out,  but  so  far  the 
therapeutic  promise  is  good.  The  phenomenon  in  question  has  been  already  observed 
in  several  very  different  cases — in  facial  palsy  (first  noted  by  Baierlacher),  in  certain 
cases  of  infantile  paralysis  (discovered  by  J.  Netten  Radcliffe,  of  London,  and  Ham- 
mond, of  New  York,  independently  of  each  other),  in  certain  cases  of  local  palsy,  e.  g., 
palsy  of  the  extensors  of  the  forearm  and  of  other  muscles,  from  lead  poisoning 
(Bruckner  and  J.  N.  Radcliffe),  in  paralysis  of  the  deltoid,  not  from  lead  (J.  N.  Rad- 
cliffe), in  certain  cases  of  muscular  atrophy  (J.  N.  Radcliffe),  and  in  paralysis  from 
traumatic  injury  of  a  nerve  (Bruckner). 


HEMORRHAGE.  83 

here  the  blood  was  collected  at  one  point  in  the  softened  nerve  matter 
to  an  extent  which  at  first  sight  suggested  the  idea  of  hemorrhage 
into  the  cord  rather  than  that  of  myelitis.  Hemorrhage  under  or 
upon  the  spinal  membranes,  the  hcematorachis  of  Ollivier,  may  be  a 
consequence  of  cerebral  hemorrhage,  the  blood  overflowing  from  the 
cranial  into  the  spinal  cavity,  and  perhaps  mixing  with  the  spinal 
fluid ;  or  it  may  result  from  spinal  congestion,  spinal  meningitis,  mye- 
litis, tetanus,  hydrophobia,  and  certain  other  maladies.  All  these 
cases,  however,  are  so  uncommon  as  to  be  little  more  than  exceptional. 
In  fact,  hemorrhage  either  into  the  substance  of  the  cord,  or  under  or 
above  the  spinal  membranes,  except  as  the  result  of  some  accidental 
injury  to  the  spine,  as  in  death  by  hanging,  or  in  cases  of  still-birth 
where  it  has  been  necessary  to  employ  much  force  to  bring  about 
the  delivery,  is,  to  say  the  least,  a  very  uncommon  affection. 

The  symptoms  of  spinal  hemorrhage  are  by  no  means  clearly  marked. 
Sudden  and  acute  pain  in  the  spine  at  the  seat  of  the  effusion,  and 
sudden  paralysis  and  loss  of  sensation,  more  or  less  complete,  in  the 
parts  below  this  point,  appear  to  be  the  chief  symptoms  where  exten- 
sive hemorrhage  has  taken  place  into  the  substance  of  the  cord.  Sud- 
den and  acute  pain  in  the  spine  would  also  seem  to  be  a  prominent 
symptom  in  hemorrhage  below  or  above  the  spinal  membranes,  but 
not  sudden  paralysis  and  anesthesia.  In  this  latter  case,  indeed, 
instead  of  paralysis  there  have  been  some  convulsive  or  spasmodic 
symptoms,  and  instead  of  anaesthesia  some  hyperaesthesia.  In  some 
cases,  as  in  one  quoted  by  Dr.  Copland,  the  pain  may  not  be  in  the 
back,  but  at  a  distance  from  the  back ;  and  in  other  cases,  and  this 
not  unfrequently,  pain  may  be  greatly  masked  by  the  shock  of  the 
accident  which  has  caused  the  hemorrhage,  or  by  the  shock  attendant 
upon  the  laceration  of  the  spinal  cord  by  the  effused  blood.  When 
the  hemorrhage  is  in  the  medulla  oblongata,  and  high  up  in  the  cord, 
the  symptoms  may  be  rather  like  those  of  epilepsy  than  anything  else 
— loss  of  consciousness,  convulsion  more  or  less  general,  choking 
noises,  and  the  rest — and  this  equally  whether  the  blood  is  effused 
into  the  substance  of  the  cord  or  around  it;  and  this  fact  suggests  the 
possibility,  to  say  the  least,  that  the  convulsive  or  spasmodic  symptoms, 
which  have  by  some  writers  (on  what  to  me  seem  to  be  insufficient 
grounds)  been  supposed  to  distinguish  hemorrhage  under  or  above 
the  spinal  membranes  from  hemorrhage  into  the  substance  of  the  cord, 
may  in  reality  be  due  to  irritation  transmitted  to  the  medulla  oblon- 
gata and  upper  part  of  the  cord,  and  not  to  irritation  acting  upon  the 
membrane  or  membranes.  Moreover,  when  the  hemorrhage  is  high 
up  in  the  cord  priapism  and  distress  of  breathing  are  found  to  figure 
conspicuously  among  the  symptoms,  as  they  do  also  in  other  cases 
where  this  part  of  the  cord  is  damaged  by  disease  or  injury.  In  a  few 
instances,  the  symptoms  of  spinal  hemorrhage  are  preceded  by  symp- 
toms indicative  of  spinal  congestion,  or  inflammation,  or  irritation. 

Eemains  of  old  apoplectic  cysts,  similar  to  those  so  often  found  in 
the  brain,  have  been  met  with  in  the  spinal  cord,  even  in  the  medulla 
oblongata  and  upper  part  of  the  cervical  region ;  but  these  signs  of 
partial  recovery  are,  to  say  the  least,  altogether  exceptional.  Indeed 


81  DISEASES    OF    THE    SPINAL    CORD. 

the  mischief  done  by  the  hemorrhage  is  generally  not  only  irreparable? 
but  very  speedily  fatal,  and  that  too  in  spite  of  everything  that  can 
be  done  to  promote  recovery. 

XI. — NON-INFLAMMATORY   SOFTENING. 

Two  well-marked  varieties  of  softening  of  the  spinal  cord  are  detect- 
ed by  the  naked  eye  —  the  red  and  white.  In  both  varieties  the 
microscope  brings  to  light  broken-down  nerve  tissue  mixed  up  with  a 
number  of  bodies  known  as  granule  masses — large  bodies,  whose  prin- 
cipal constituent  is  fat ;  black  looking,  from  not  transmitting  light ; 
and  somewhat  like  mulberries,  from  being  built  up  of  a  number  of 
round  bodies  or  granules.  "It  was  once  thought,"  said  Dr.  Wilks, 
"that  these  masses  denoted  inflammation.  But  you  find  them  in  any 
degenerating  part,  as  a  decaying  strumous  gland,  or  a  cancerous 
tumour,  or  a  phthisical  lung :  and  the  question  of  their  formation  in 
the  brain  or  cord  is  not  yet  answered ;  whether  they  originate  in 
inflammatory  cells,  or  are  the  natural  cells  of  the  nerve  structure  de- 
generated. In  some  you  may  still  see  a  wall  and  a  nucleus,  which 
points  to  the  former  opinion  as  the  more  correct."  The  red  variety 
of  softening  is  often  in  parts  yellow  rather  than  red :  the  redness  being 
due  to  increased  vascularity  or  effused  blood  corpuscles,  one  or  both ; 
the  yellowness  to  the  presence  of  fibrillated  tissue,  nucleated  fibre, 
pus  corpuscles,  or  some  other  form  of  distinctly  inflammatory  product. 
In  a  word,  there  can  be  no  doubt  of  the  inflammatory  origin  of  the 
red  variety  of  softening.  In  the  white  variety  of  softening,  on  the 
other  hand,  there  are  generally  an  atheromatous  state  of  the  vessels 
and  other  signs  of  true  degeneration,  the  vascularity  is  evidently 
diminished,  and  there  is  an  absence  of  those  distinctly  inflammatory 
products  which  have  just  been  enumerated.  It  would  seem,  indeed, 
that  the  white  variety  of  softening  differs  essentially  from  the  red,  in 
that,  instead  of  being  the  result  of  inflammation,  it  is  brought  about 
by  the  parts  being  starved  and  atrophied  for  want  of  blood.  With 
respect  to  the  reality  of  these  differences  between  these  two  varieties 
of  softening  there  appears  to  be  little  or  no  reason  for  doubt :  at  the 
same  time  it  must  not  be  forgotten  that  it  is  not  always  easy  to  draw 
the  line  between  these  two  varieties,  and  that  they  both  may  exist 
together  in  the  same  cord. 

The  symptoms  of  non-inflammatory  softening  would  seem  to  be 
identical  with  those  of-the  more  chronic  forms  of  myelitis.  The  more 
tardy  the  development  of  these  symptoms,  and  the  older  the  patient 
in  years  or  in  constitution,  the  more  likely  is  the  case  to  be  one  of 
non-inflammatory  softening :  and  this  is  all  that  can  be  said  in  the 
matter  of  diagnosis.  Practically,  however,  this  want  of  definiteness 
is  of  no  moment;  for  in  the  chronic  form  of  myelitis  the  degenerative 
process  has  more  to  do  in  bringing  about  the  diseased  changes  in  the 
cord  than  the  inflammatory,  and  more  to  do  also  in  supplying  the 
indications  for  treatment.  Nay,  it  may  even  be  held  that  the  same 
remark  applies  to  some  extent  to  the  more  acute  forms  of  myelitis  as 
well  as  to  the  more  chronic,  for  it  is  with  the  ruin  rapidly  produced 


TUMOURS,   ETC.  85 

by  the  inflammation  rather  than  with  the  inflammation  itself  that  the 
practitioner  in  medicine  has  to  cope  almost,  if  not  altogether,  from  the 
very  onset  of  the  disease. 

XII. — INDURATION. 

Like  the  opposite  condition  of  softening,  induration  (sclerosis)  of 
the  spinal  cord  is  one  of  the  consequences  of  myelitis,  chronic  or  acute; 
of  the  chronic  form  more  especially.  Induration  of  the  cord  is  gen- 
erally associated  with  atrophy — atrophy  often  more  marked  in  the 
white  matter  than  in  the  gray — and  with  a  condition  so  curiously 
bloodless  that  a  section  is  not  unlike  that  of  white  of  egg  boiled  hard. 
In  its  highest  degree  the  cord  may  have  a  leather-like  or  fibre-carti- 
laginous hardness  and  consistency.  Induration  is  a  much  less  common 
change  than  softening:  it  has  no  symptoms  by  which  it  can  be  distin- 
guished from  softening :  and  it  is  often  met  with  when  it  was  not 
expected,  and  under  very  different  circumstances,  as  after  acute  mye- 
litis on  the  one  hand,  or  after  long-standing  epileptic  disease  on  the 
other. 

XIII. — ATROPHY  AND  HYPERTROPHY. 

Atrophy  of  the  spinal  cord,  like  atrophy  of  the  brain,  is  one  of  the 
changes  which  must  be  looked  upon  as  natural  to  old  age.  In  elderly 
persons,  indeed,  the  cord  becomes  shorter  and  narrower  and  firmer,  the 
spinal  fluid  increases  in  quantity,  so  as  to  fill  the  space  left  vacant  by 
the  shrunken  cord,  and  the  spinal  nerves  are  sensibly  wasted  at  both 
their  roots.  All  this  has  been  abundantly  proved  by  Chaussard, 
Ollivier,  and  others.  Atrophy,  more  or  less  general,  is  also  associated 
with  many  forms  of  paralysis  in  which  the  cord  has  been  long  left  in  a 
state  of  comparative  functional  inactivity ;  and  local  atrophy  is  one  of 
the  consequences  of  tumour,  displaced  vertebra,  or  anything  which 
exercises  pressure  upon  the  cord.  Of  partial  forms  of  atrophy  re- 
sulting from  disease,  the  only  one  about  which  there  is  any  certain 
knowledge  is  that  which  is  associated  with  the  disease  called  locomotor 
ataxy — namely,  atrophy  of  the  posterior  columns;  and  about  this 
form  enough  has  already  been  said  in  a  separate  article. 

In  a  few  instances  the  spinal  cord  has  been  found  to  be  so  much 
enlarged,  apparently  by  a  true  hypertrophy  of  its  natural  tissues,  as 
to  occupy  the  whole  space  of  the  vertebral  canal;  but  most  generally 
what  seems  to  be  hypertrophy  at  first  sight  is  due,  chiefly  at  least,  to 
congestive  swelling  and  oedema.  True  hypertrophy  has  been  met 
with  in  the  foetus:  it  occurs  mostly  in  children:  and  it  presents,  so 
far  as  is  known,  no  symptoms  by  which  it  can  be  recognized.  Hyper- 
trophy of  the  brain  is  a  very  uncommon  affection,  but  it  is  common 
as  compared  with  hypertrophy  of  the  spinal  cord. 

XIV.— TUMOUR,  &c. 

"Tubercle  and  cancer,"  says  Eokitansky,  " are  frequent  in  the  brain, 
unfrequent  in  the  spinal  cord.  Tubercle  I  have  observed  only  in 
combination  with  other  advanced  tuberculoses.  Its  principal  seat  is 


86  PISEASES    OF    THE    SPINAL    CORD. 

the  cervical  or  lumbar  portion  of  the  cord,  where  it  sometimes  oc- 
cupies the  white  fibres,  sometimes  the  gray  substance.  As  in  the 
brain,  it  leads  to  inflammation  (red  softening)  and  to  yellow  softening. 
I  have  never  seen  a  tuberculous  cavity  in  the  cord.  Sometimes 
several  tubercles  are  grouped  together,  none  exceeding  the  size  of 
millet  or  hempseed ;  at  other  times  only  one  exists,  which  is  of  large 
dimensions,  equalling  a  pea  or  a  bean.  Exclusively  of  several  cases 
of  circumscribed  callous  induration  of  the  white  columns,  as  to  the 
cancerous  nature  of  which  I  am  still  in  doubt,  I  have  met  with  but 
one  case  of  cancer  of  the  cord.  It  was  a  solitary  nodule  of  medullary 
cancer.  Ollivier  mentions  several  examples  of  diffused  carcinomatous 
growths,  as  well  as  of  the  so-called  colloid  cancer.  Among  the  entozoa 
I  have  repeatedly  seen  the  cysticercus  in  the  cervical  portion  of  the 
spinal  marrow.  The  acephalocyst  sacs,  as  far  as  has  been  observed, 
have  no  connection  with  the  cord ;  their  nidus  is  even  outside  the 
dura  mater.  In  one  case  the  cyst  forced  its  way  into  the  cavity  of  the 
arachnoid." 

Nor  are  exostoses,  cartilaginous  growths,  or  aneurisms  frequently 
met  with  in  positions  which  can  exercise  pressure  upon  the  spinal 
cord.  Cartilaginous  growths,  or  rather  bony  plates,  it  is  true,  are  not 
unfrequently  met  with  in  the  visceral  arachnoid  of  the  cord — a  con- 
dition which  appears  to  be  rarely  met  with  in  the  brain ;  but  these 
growths  or  plates  can  scarcely  be  brought  under  the  head  of  tumours. 
Except,  perhaps,  in  connection  with  scrofulous  disease  of  the  vertebras, 
the  pia  mater  of  the  cord  is  not  the  seat  of  tuberculous  deposits ;  and 
here  again  is  another  point  of  difference  between  the  pathological  his- 
tory of  the  spinal  cord  and  the  brain,  for  it  is  a  well-known  fact  that 
the  pia  mater  of  the  brain  is  a  favourite  seat  of  these  deposits. 

The  symptoms  produced  by  tumour  vary  greatly.  Neuralgic  pain 
in  the  back,  over  the  seat  of  the  tumour,  appears  to  be  an  almost  con- 
stant symptom.  "  Pain,"  says  Dr.  Eeynolds,  "  is  more  marked  in  cases 
of  carcinoma  than  of  tubercle."  If  a  particular  nerve  be  irritated  by 
the  tumour,  there  may  be  pain,  tingling,  or  some  other  anomalous 
sensation  in  the  part  or  parts  supplied  by  its  sentient  fibres,  or  some 
morbid  form  of  contraction  in  the  muscles  supplied  by  its  motor  fibres. 
If  a  particular  nerve  be  pressed  upon  more  decidedly  by  the  tumour, 
there  may  be  local  anaesthesia,  or  paralysis  instead  of  morbid  sensations 
or  muscular  contractions.  It  is  but  seldom,  however,  that  these  symp- 
toms of  irritation  or  pressure  are  so  strictly  localized ;  and  in  fact,  the 
presence  of  the  tumour  is  made  known  usually  only  by  more  general 
symptoms  of  irritation,  or  compression,  or  inflammation,  which,  instead 
of  being  in  any  way  pathognomonic  of  tumour,  may  arise  from  many 
other  causes.  "There  is,  indeed,"  as  Dr.  Gull  says,  "no  symptom,  or 
single  group  of  symptoms,  which,  taken  alone,  can  serve  as  a  secure 
basis  for  diagnosis."  Tuberculous  or  carcinomatous  deposits  else- 
where, with  signs  of  the  peculiar  dyscrasia  of  tubercle  or  cancer, 
aneurism  elsewhere,  nodes  elsewhere,  may  help  to  a  diagnosis  by 
showing  that  symptoms  which  appear  to  point  to  a  tumour  may  have 
such  a  cause,  and  at  the  same  time  may  supply  some  information  as  to 
the  special  character  of  the  tumour;  but  this  possibility  of  help  in 


COMPRESSION.  87 

diagnosis  is  too  remote  to  be  of  much  practical  value,  if  any.  It  may 
be  supposed  that  any  scrofulous  deposit  in  the  cord  is  more  likely  to 
occur  in  children,  and  any  cancerous  growth  in  older  persons;  but 
even  this  rule  has  too  many  exceptions  to  make  it  of  much  use. 

XV. — CONCUSSION. 

Concussion  of  the  spinal  cord,  like  concussion  of  the  brain,  is  the 
result  of  a  fall  from  a  height,  a  blow  on  the  back,  or  some  other  acci- 
dent, and  its  symptoms  vary  with  the  intensity  of  the  shock.  Sudden 
paralysis  and  loss  of  sensation,  more  or  less  complete,  with  some  ina- 
bility to  pass  water  or  to  prevent  the  escape  of  flatus  or  feces,  are  the 
more  special  symptoms.  Sudden  and  marked  failure  in  the  circulation 
and  respiration,  as  shown  by  pallor,  feebleness  of  the  pulse,  diminished 
temperature,  slow  and  shallow  breathing,  and  other  signs  of  common 
shock  are  also  associated  with  the  more  especial  symptoms.  Great 
pain  along  the  spine  or  in  some  part  of  the  spine  has  been  considered 
as  one  of  the  symptoms  of  spinal  concussion;  but  neither  pain  nor 
spasm  are  met  with  in  the  cases  which  I  have  examined;  and  Dr. 
Reynolds  comes  to  the  same  conclusion,  for,  speaking  of  these  cases, 
he  says :  "  There  is  in  them  neither  marked  pain  nor  spasm."  Indeed, 
in  the  majority  of  cases  the  patient  is  obviously  rendered  incapable  of 
experiencing  either  pain  or  spasm  by  being  stunned. 

The  symptoms  of  spinal  concussion  not  unfrequently  issue  in  those 
of  spinal  congestion,  or  myelitis,  or  spinal  meningitis,  or  else  death 
without  any  signs  of  reaction  may  be  the  result.  Often,  without  pass- 
ing into  any  definite  disease,  the  cord,  even  after  what  might  at  first 
seem  to  be  only  a  slight  degree  of  concussion,  may  not  recover  its 
former  power  perfectly,  the  patient  ever  afterwards  being  weak  in 
many  respects,  especially  in  his  legs  and  bladder.  Indeed,  concussion 
of  the  spine  sufficiently  severe  to  produce  at  the  time  any  marked  de- 
gree of  paralysis  in  the  limbs  and  bladder  and  lower  bowel,  with  loss 
of  sensation,  is  certainly  a  very  grave  matter,  and  it  may  be  questioned 
whether  in  such  a  case  recovery  is  ever  more  than  partial. 

The  appearances  after  death  may  present  nothing  unnatural,  or  they 
may  be  those  of  hemorrhage  more  or  less  extensive.  It  is  very  pos- 
sible that  the  cases  in  which  severe  pain  in  the  back  was  a  symptom 
would  prove,  if  all  the  facts  were  fully  known,  to  be  cases  in  which 
the  symptoms  of  concussion  were  mixed  up  with  those  of  hemorrhage: 
at  any  rate,  there  was  hemorrhage  in  one  case  of  spinal  concussion  in 
which  pain  in  the  spine  was  a  conspicuous  symptom,  which  case  came 
under  my  notice  not  long  ago.  In  fatal  cases,  in  which  the  reaction 
after  the  concussion  has  issued  in  inflammatory  and  other  changes  in 
the  cord,  these  changes  will  be  met  with  after  death ;  and  if  fracture 
or  dislocation  of  the  vertebra  was  produced  at  the  time  of  the  con- 
cussion, the  evidence  of  such  injury  will  of  course  not  be  wanting. 

XVI. — COMPRESSION. 

When  the  spinal  cord  is  compressed  by  a  dislocated  or  fractured 
vertebra,  by  a  tumour,  by  a  bullet  or  in  any  other  way,  the  symp- 


88  PISEASES    OF    THE    SPINAL    CORD. 

toms  will  of  course  vary  with  the  seat  and  degree  of  compression. 
The  symptoms  will,  in  fact,  be  as  variable — for  they  will  be  the  same — 
as  those  which  are  produced  by  experimental  division  of  the  parts  com- 
pressed, and  about  which  more  than  is  convenient  had  to  be  said  in 
the  preliminary  remarks.  All,  therefore,  that  is  necessary  here  is  to 
refer  to  those  preliminary  remarks  for  the  information  which  may 
help  to  make  the  symptoms  of  compression  intelligible,  and,  in  passing, 
to  express  a  hope  that  trephining  or  other  operative  procedures  which 
have  been  recommended  and  practised  in  certain  cases  of  spinal  com- 
pression may  not  be  altogether  unjustifiable. 

XVII. — CARIES  OF  THE  VERTEBRAL  COLUMN. 

This  disease  is  usually  limited  to  the  bodies  of  the  vertebras  and  to 
the  intervertebral  substances,  but  sometimes  it  extends  backwards  to 
the  arches  and  processes  of  the  vertebrae  as  well.  It  commences,  very 
generally,  in  the  middle  dorsal  region,  and,  as  generally,  it  does  not 
extend  beyond  this  region ;  but  there  is  no  part  of  the  spinal  column 
in  which  it  may  not  begin,  or  to  which  it  may  not  extend ;  it  invari- 
ably, when  sufficiently  advanced,  gives  rise  to  "angular  curvature," 
or  projection  directly  backwards,  of  the  diseased  part  of  the  spine,  this 
deformity  being  due  to  the  way  in  which  the  thinned  and  diseased 
bodies  of  the  vertebras  become  crushed  in  under  the  weight  of  the 
upper  part  of  the  body.  In  the  great  majority  of  cases  caries  of  the 
vertebrae  is  an  unmistakably  strumous  affection,  being  neither  more 
nor  less  than  tuberculous  infiltration  of  the  bodies  of  the  vertebrae ; 
and  the  changes  in  the  bone  are  due  to  the  melting  down  of  this  de- 
posit rather  than  to  any  strictly  inflammatory  process. 

The  earlier  symptoms  of  caries  of  the  vertebrae  are  not  at  all  well 
marked.  Of  these  the  most  conspicuous  must  be  reckoned — weak- 
ness in  the  back,  generally  in  the  dorsal  region,  with  aching  or  pain, 
more  or  less  severe,  in  the  weak  part,  causing  a  disposition  to  lean 
forwards  and  to  use  the  arms  as  props ;  some  prominence  of  the  spi- 
nous  processes  of  the  weak  and  painful  part  of  the  spine,  with  some 
puffiness  of  the  overlying  skin;  a  feeling  of  undue  heat,  or  even 
burning,  in  the  weak  and  painful  and  prominent  part,  which  is  not  felt 
in  other  parts. of  the  spine,  when  a  sponge  soaked  in  moderately  warm 
water  is  passed  down  the  spine ;  and  a  state  of  tenderness  on  pressure 
or  percussion,  which  is  equally  restricted  to  the  same  weak  and  painful 
and  prominent  part.  Afterwards,  when  the  disease  is  more  advanced, 
there  are  more  marked  symptoms,  namely,  these:  unmistakable  "an- 
gular curvature,"  the  formation  of  abscess,  slight  hectic  in  the  evening, 
a  feeling  of  constriction  around  the  waist,  it  may  be,  and  still  later, 
more  or  less  paralysis  of  the  legs,  more  or  less  loss  of  control  over  the 
bladder  and  bowel,  and  other  symptoms  indicative  of  secondary 
myelitis  or  spinal  meningitis.  Abscess  may  be  one  of  the  earlier 
symptoms  preceding  any  obvious  deformity,  or  it  may  not  occur  at  all. 
In  fact,  abscess  appears  to  be  a  symptom  of  strumous  disease  of  the 
vertebras  exclusively,  and  not  of  the  non-strumous  variety  of  caries. 
When  it  does  occur,  which  is  certainly  in  the  great  majority  of  cases, 


SPINA    BIFIDA,  ETC. 

there  is  usually  some  diminution  of  pain  and  other  evidences  of  irri- 
tation. When  it  does  occur,  as  is  well  known,  it  generally  makes  its 
appearance  at  a  distance  from  the  diseased  vertebra,  most  commonly 
as  "  psoas  abscess"  in  the  groins,  but  by  no  means  exclusively  in  this 
form  and  locality.  It  is  seldom  that  the  spinal  cord  becomes  com- 
pressed  by  the  giving  way  of  the  bodies  of  the  vertebras  in  the  pro- 
gress of  the  disease  ;  but  sooner  or  later  it  almost  constantly  happens 
that  the  cord  or  its  membranes  opposite  the  diseased  vertebras  become 
the  seat  of  inflammatory  changes,  which  changes,  rather  than  the  drain 
from  an  abscess,  are  indeed  the  reason  why,  in  so  many  cases,  sooner 
or  later,  caries  of  the  vertebrae  proves  to  be  destructive  to  life. 

The  diagnosis  between  "  angular  curvature"  from  caries  of  the  spine, 
and  the  curvatures  forward,  backward,  and  sideways,  without  other 
structural  changes  in  the  vertebral  column  than  those  of  simple  adapt- 
ation to  the  altered  position,  is  not  very  difficult.  These  latter  curva- 
tures, in  fact,  want  all  the  special  and  grave  features  which  have  been, 
indicated  as  characterizing  the  former.  Nor  yet  is  the  diagnosis  difficult 
between  "  angular  curvature"  in  its  earliest  stage  and  spinal  irritation, 
with  which  it  is  sure  to  be  associated,  and  with  which  there  is  certainly 
no  small  danger  of  its  being  confounded.  This  topic  has  been  already 
touched  upon  when  speaking  of  spinal  irritation,  and  here  it  is  enough 
to  say  that  the  occurrence  of  the  symptoms  which  are  present  in  the 
beginning  of  caries  of  the  vertebra  (which  are  no  other  than  those 
which  may  belong  to  simple  spinal  irritation),  in  children  or  youths 
of  a  manifestly  scrofulous  habit — at  an  age,  that  is  to  say,  and  in  a 
habit,  in  which  the  symptoms  of  simple  spinal  irritation  are  not  likely 
to  be  met  with — are  sufficient  to  do  more  than  create  a  bald  suspicion 
of  the  existence  of  disease  of  the  vertebral  column. 

The  prognosis  of  caries  of  vertebrae  is  always  bad  enough.  A  hump- 
back is  the  best  result  to  be  hoped  for.  The  end  to  be  aimed  at  in 
treatment  is,  of  course,  to.  promote  anchylosis  of  the  diseased  bones  of 
the  vertebras  by  allowing  them  to  fall  together — by  favouring,  that  is 
to  say,  the  deformity  which  is  inevitable  by  letting  the  back  bend 
and  not  by  trying  to  prevent  it  by  keeping  the  back  straight — and  to 
keep  up  the  strength  in  every  way.  But  these  are  matters  which  I 
cannot  touch  upon  without  trespassing  upon  the  domains  of  surgery, 
and  I  therefore  leave  them  to  those  who  are  better  able,  and  whose 
right  it  is  to  deal  with  them. 

XVIII.— SPINA  BIFIDA,  &c. 

The  commonest  congenital  affection  to  which  the  spinal  cord  is  liable 
is  .dropsy,  or  hydrorachis,  and  of  this  dropsy  spina  bifida  is  the  variety 
most  frequently  met  with,  and  of  most  practical  interest.  The  spine 
is  bifid  in  this  disorder  from  the  non-development  or  separation  of  the 
spinal  processes  and  laminas,  and  the  consequence  of  this  malformation 
is  that  an  opening  is  left  through  which,  very  often,  the  dropsical  fluid 
presses  outwards,  and  distends  in  so  doing  the  integuments  and  sub- 
jacent tissues  into  an  hernial  tumour.  Very  generally  congenital 
hydrocephalus  is  associated  with  congenital  hydrorachis.  The  fluid 


90  DISEASES    OF    THE    SPINAL    CORD. 

in  hydrorachis  is  precisely  of  the  same  constitution  and  character  as 
that  which  is  met  with  in  hydrocephalus  :  it  varies  in  quantity  from 
a  few  ounces  to  several  pints:  it  accumulates  between  the  arachnoid 
and  pia  mater,  in  the  arachnoid  sac,  in  the  central  canal  of  the  cord, 
and  even  outside  the  dura  mater,  sometimes  in  one  place,  sometimes 
in  another,  sometimes  in  more  places  than  one.  The  hernial  tumour 
into  which  this  dropsical  fluid  bulges  outwardly  varies  greatly  both 
in  position  and  size,  and  in  the  condition  of  its  coverings:  it  is  almost 
invariably  met  with  in  the  lumbar  region,  but*  it  may  be  in  any  region  : 
it  is  usually  of  the  size  of  a  walnut  or  orange,  but  it  may  be  as  large 
as  a  child's  head,  or  even  larger;  it  may  be  single  or  multiple:  its 
bulk  may  vary  considerably  under  different  circumstances,  or  not  at 
all,  becoming,  if  it  vary,  fuller  and  more  tense  if  the  position  of  the 
child  be  made  such  as  to  cause  the  fluid  to  flow  into  it,  emptier  and 
flaccid  if  this  position  be  altered  so  that  this  fluid  may  run  out  of  it, 
or  if  pressure  be  made  upon  it  so  as  to  bring  about  the  same  result: 
it  may  swell  during  expiration  and  fall  during  inspiration :  it  may 
present  distinct  fluctuation  or  none  at  all;  and  the  skin  over  it  may 
be  sound,  thickened,  inflamed,  ulcerated,  gangrenous,  covered  with 
tufts  of  hair,  and  so  on.  The  dura  mater  and  its  lining  of  arachnoid 
membrane  always  enter  into  the  composition  of  the  coverings  of  the 
tumour,  and  these  are  the  only  constant  elements  in  these  coverings. 
In  the  lumbar  region,  the  cord  and  its  nerves,  which  are  generally 
rudimentary,  are  out  of  the  tumour  altogether:  in  the  cervical  and 
upper  dorsal  region,  on  the  contrary,  it  is  no  uncommon  thing  for  the 
cord  and  its  nerves  to  be  adherent  to  the  walls  of  the  tumour. 

In  spina  bifida  the  lower  limbs  are  generally  paralyzed  as  well  as 
the  bladder  and  lower  bowel,  and  not  unfrequently  there  is,  in  addition 
to  the  spinal  deformity,  deficiency  of  the  abdominal  walls,  hernia  of 
the  bladder,  imperforate  anus,  &c.  But  few  cases  recover,  or  even 
improve,  death  happening  generally  at  an  early  period  either  in  con- 
vulsions or  from  spinal  inflammation,  the  immediate  cause  often 
being  the  bursting  of  the  tumour:  still  there  are  cases  on  record  in 
which  life  has  been  prolonged — and  this  too  with  tumours  of  no  small 
size — not  only  for  a  few  months,  but  for  17,  18,  19,  21,  and  even  50 
years. 

There  is  little  to  be  done  for  the  relief  of  spina  bifida.  Pressure 
on  the  tumour  by  means  of  an  air-pad  and  suitable  bandages  can  do 
no  harm ;  and  occasional  punctures  with  a  grooved  needle,  as  recom- 
mended by  Sir  Astley  Cooper,  may  be  a  justifiable  measure.  Even 
cures  have  resulted  from  a  combination  of  these  punctures  with  pres- 
sure. "  All  the  plans  of  treatment,"  says  Mr.  Erichsen,  "  by  which 
the  tumour  is  opened  and  air  allowed  to  enter  it,  are  fraught  with 
danger,  and  will,  I  believe,  inevitably  be  followed  by  the  death  of  the 
child  from  inflammation  of  the  meninges  of  the  cord  and  convulsions." 

There  are  several  other  congenital  affections  of  the  cord,  of  which 
the  best  account  is  still  to  be  found  in  the  classical  pages  of  Ollivier. 
The  cord  may  be  entirely  absent  (amye'lie) ;  or  it  may  be  imperfect 
(atelomyelie).  Of  the  imperfect  forms  of  cord  there  are  several  va- 
rieties. The  upper  part  may  be  wanting,  as  in  anencephalous  and 


SPINA    BIFIDA,   ETC.  91 

acephalous  monsters.  The  cord  may  be  bifurcated  at  one  extremity 
or  the  other,  at  the  upper  extremity  in  monsters  with  two  heads  and 
one  body,  at  the  lower  extremity  in  monsters  with  one  head  and  two 
bodies.  It  may  be  double.  It  may  vary  greatly  in  dimensions,  being 
larger  or  smaller,  longer  or  shorter  than  natural — longer,  for  example, 
in  monsters  with  tails,  shorter  in  monsters  of  a  contrary  sort.  It  may, 
as  in  one  form  of  hydrorachis,  be  little  more  than  a  long  bag  in  con- 
sequence of  the  distension  of  the  central  canal  of  the  cord  with  the 
dropsical  fluid.  Or  it  may  be  discoloured,  as  it  is  in  the  state  which 
Ollivier  designates  kirronese  or  coloration  icterique.  These  malformations 
or  morbid  conditions,  however,  are  of  theoretical  rather  than  of  prac- 
tical interest :  and  therefore  they  do  not  form  fit  subjects  for  further 
notice  in  an  article  like  the  present,  which  has  solely  a  practical  end 
in  view. 


92  EPIDEMIC    CEREBRO-SPINAL    MENINGITIS. 


II. 

EPIDEMIC  CEREBRO-SPINAL  MENINGITIS. 

BY  J.  NETTEN  RADCLIFFE. 

DEFINITION. — An  acute,  epidemic  disease,  characterized  by  profound 
disturbance  of  the  central  nervous  system,  indicated,  at  the  outset, 
chiefly  by  shivering,  intense  headache  or  vertigo,  or  both,  and  per- 
sistent vomiting :  subsequently  by  delirium,  often  violent,  alternating 
with  somnolence,  or  a  state  of  apathy  or  stupor;  an  acutely  painful 
condition  with  spasm — sometimes  tetanoid — of  certain  groups  of 
muscles,  especially  the  posterior  muscles  of  the  neck,  occasioning  re- 
traction of  the  head;  and  an  increased  sensitiveness  of  the  surface  of 
the  body.  Throughout  the  disease,  there  is  marked  depression  of  the 
vital  powers;  not  unfrequently  collapse:  and  in  its  course  an  eruption 
of  vesicles,  petechise,  or  purpuric  spots,  or  mottling  of  the  skin,  is  apt 
to  occur.  If  the  disease  tend  to  recovery,  the  symptoms  gradually 
subside  without  any  critical  phenomena,  and  convalescence  is  pro- 
tracted ;  if  to  a  fatal  termination,  death  is  almost  invariably  preceded 
by  coma.  After  death,  the  enveloping  membranes  of  the  brain  and 
spinal  cord  are  found  in  a  morbid  state,  of  which  the  most  notable  signs 
are  engorgement  of  the  bloodvessels,  usually  excessive,  and  an  effusion 
of  sero-purulent  matter  into  the  meshes  of  the  pia  mater,  and  beneath 
the  arachnoid.1 

SYNONYMS. — (a)  Technical: — Cerebro-spinal  fever  (Royal  College 
of  Physicians) ;  cerebro-spinal  arachnitis ;  typhus  syncopalis ;  tifo 
apoplettico  tetanico ;  typhus  cerebro-spinal  (Boudin) ;  cerebral  typhus ; 
epidemic  meningitis  (StilU,  U.S)  ;  petechial  fever  (G.  B,  Wood,  U.S.) ; 
fever  with  cerebro-spiual  meningitis  (S.  Gordon)  ;  malignant  purpuric 
fever  ( W.  Stokes) ;  malignant  purple  fever ;  nervo-purpuric  fever 
(Mapother) :  malignant  purpurse  (McSwinney)  :  pestilential  purpune 

1  Since  the  completion  of  this  article  the  Royal  College  of  Physicians,  in  its  "  Nomen- 
clature of  Disease,"  has  adopted  the  following  designation  and  definition  of  this 
malady:  "  Cerebro-spinal  Fever.  A  malignant  epidemic  fever,  attended  by  painful 
contraction  of  the  muscles  of  the  neck,  and  retraction  of  the  head.  In  certain  epi- 
demics it  is  frequently  accompanied  by  a  profuse  purpuric  eruption,  and  occasionally 
by  secondary  effusions  into  certain  joints.  Lesions  of  the  brain  and  spinal  cord  and 
their  membranes  are  found  on  dissection." 


DESCRIPTION    OF    THE    DISEASE.  93 

(Banks) ;  febris  nigra  (R.  D.  Lyons). — (b)  Popular  : — Spotted  fever 
(New  England);  cold  plague  (Southern  States,  U.S.);  Kolik,  Nacken- 
starre,  Genickkrampf  (Germany);  Nacksjuka,  Dragsjuka  (Sweden). 

DESCRIPTION  OF  THE  DISEASE. — 1.  General  Symptoms: — Epidemic 
cerebro-spinal  meningitis  is  observed  in  three  principal  forms:  (A. — 
Simple),  in  which  the  symptoms  indicative  of  disorder  of  the  nervous 
centres  predominate  throughout  the  whole  course  of  the  disease  ;  (B. — 
Fulminant),  in  which  the  depressed  state  of  the  vital  powers,  with 
profound  blood  change — as  shown  by  hemorrhage  of  various  forms 
into  the  cutis — characterize  the  disease;  and  (c. —  Purpuric)  in  which 
the  cerebro-spinal  symptoms  and  the  symptoms  which  mark  blood- 
change  (petechice,  purpurce,  vibices,  &c.),  and  flagging  of  the  vital  powe.rs, 
occur  together.  The  proportion  in  which  the  three  forms  of  the  dis- 
ease are  manifested  varies  considerably  in  different  epidemics.  In 
every  outbreak  cases  are  observed  which  link,  by  insensible  gradations, 
one  form  with  another;  while  in  other,  and  rarer  cases,  the  character- 
istic symptoms  of  the  three  forms  are  merged  together.  Continental 
and  American  writers  have  described  an  abortive  form  of  the  disease, 
the  term  being  given  (a)  to  certain  anomalous  symptoms  observed  in 
communities  among  which  the  disease  is  active :  and  (b)  to  sundry 
characteristic  symptoms  of  the  malady  of  transitory  duration  :  such  as 
severe  cephalalgia :  a  sense  of  dragging  at  the  back  of  the  neck,  or 
actual  slight  retraction  of  the  head;  cardialgia,  enteralgia; — these 
symptoms  often  ending  contemporaneously  with  the  appearance  of 
profuse  perspiration,  or  epistaxis. 

(A)  Simple  ^Epidemic  Cerebro-spinal  Meningitis. — In  the  majority  of 
the  cases  before  the  onset  of  the  disease  the  patient  suffers  from  more 
or  less  indisposition.  There  are  discomfort  in  the  head,  neuralgic 
pains  in  the  back,  the  principal  groups  of  muscles,  and  the  abdomen ; 
failure  of  the  appetite,  indifference  to  exertion,  perhaps  also  slight 
shiverings,  and  a  quasi-febrile  state.  These  indications  of  disordered 
innervation  may  persist  from  three  to  seven  days,  or  be  manifested 
only  during  a  few  hours,  before  the  confirmed  malady  fully  declares 
itself.  But  in  numerous  cases  the  onset  of  the  disease  is  sudden  and 
characteristic.  In  both  classes  of  cases  the  accession  of  the  malady  is 
declared  by  similar  well-marked  signs.  Acute  shivering  is  followed 
or  accompanied  by  severe,  commonly  intolerable,  headache  or  vertigo, 
or  both  ;  and  after  a  short  interval,  or  contemporaneously,  profuse  and 
irrepressible  vomiting  takes  place,  rarely  preceded  by  nausea.  Or 
vomiting  may  be  the  initiatory  symptom,  the  shivering,  headache,  or 
vertigo  following  quickly  after.  The  intensity  of  the  symptoms 
marking  the  onset  of  the  disease  is  remarkable  and  characteristic.  The 
sickness  is  often,  and  from  the  outset  accompanied  by  severe  abdomi- 
nal pain,  apparently  neuralgic ;  and  not  ^infrequently  this  pain  precedes 
the  disorder  of  the  stomach,  as  the  cephalalgia  precedes  mental  con- 
fusion. In  like  manner,  the  shivering  ushers  in,  or  is  accompanied  by, 
an  acutely  painful  state  of  the  muscles,  more  or  less  general,  the  fore- 
runner of  spasm.  Cephalalgia  and  delirium,  abdominal  neuralgia  and 


94  EPIDEMIC    CEREBRO-SPINAL    MENINGITIS. 

vomiting,  and  myalgia  and  spasm  are  the  principal  morbid  factors  of 
simple  epidemic  cerebro-spinal  meningitis.  They  distinguish  the  ma- 
lady, and  the  varying  prominence  with  which  they  are  met  in  different 
outbreaks  gives  rise  to  many  diversities  in  the  grouping  of  symptoms 
during  the  progress  of  the  disease.  The  onward  course  of  the  disorder 
is  usually  rapid.  The  headache  continues,  often  without  a  lull;  vertigo 
occurs  frequently ;  and  after  the  lapse  of- a  very  brief  period,  measured 
usually  by  a  few  hours,  the  mind  becomes  confused,  and,  in  some  cases, 
a  state  of  restlessness  supervenes  not  unlike  that  observed  in  delirium 
tremens.  The  mental  confusion  assumes  the  form  of  muttering  deli- 
rium, with  periods  of  somnolence,  often  interrupted  by  cries  provoked 
by  the  intense  cephalalgia,  or  by  the  neuralgic  pain  elsewhere ;  or  the 
patient  falls  into  a  state  of  apathy  or  stupor,  from  which  he  may  be 
partially  roused,  but  into  which  he  relapses  when  left  undisturbed,  the 
mind  acting  as  in  a  dream;  or  there  is  acute  and  violent  delirium. 
Contemporaneously  with,  or  immediately  prior  to,  the  mental  dis- 
turbance, the  painful  state  of  the  muscles  increases,  certain  groups 
being  more  manifestly  affected  than  others,  especially  the  posterior 
muscles  of  the  neck,  the  muscles  of  the  spinal  column,  and  those  of  the 
lower  extremities.  The  pain  often  of  an  acutely  neuralgic  character, 
shoots  along  the  spine  and  limbs,  and  across  the  walls  of  the  abdomen. 
Partly  as  a  voluntary  action,  partly  as  a  consequence  of  spasm  of  the 
painful  muscles,  the  head  is  drawn  backwards.  The  retraction  thus 
arising  is  one  of  the  commonest  and  most  characteristic  symptoms  of 
the  disease.  As  the  malady  advances  an  actual  or  apparent  tetanoid 
contraction  of  other  groups  of  muscles  may  occur,  the  trunk  most 
frequently  being  curved  backwards,  and  the  legs  bent  upon  the  thighs. 
At  the  same  time  there  may  be  fleeting  spasmodic  actions  of  some  of 
the  muscles  of  the  face,  and  occasionally  of  the  eyeballs ;  or  in  some 
cases  tonic  contraction  of  these  muscles,  giving  rise  to  the  so-called 
sardonic  laugh,  or  to  persistent  strabismus.  In  many  cases  cutaneous 
sensibility  is  much  exaggerated,  and  very  frequently  a  vesicular  or 
roseolar  eruption  is  developed,  the  former  particularly  about  the  lips. 
The  aspect  of  the  patient  as  the  disease  advances  is  dependent  upon 
the  degree  of  pain,  the  state  of  delirium  or  stupor,  and  extent  of  spasm 
which  may  be  present.  The  countenance  is  rigid  and  contracted,  the 
expression  of  face  betokening  acute  pain ;  or  it  is  dominated  by  the 
delirious  fancies;  or  reflects  the  mental  torpidity;  or  is  distorted  by 
spasm.  There  is  frequently  a  slight  effusion  of  the  eyes,  altogether 
different  from  the  dusky  appearance  of  typhus ;  and  the  face  is  com- 
monly pale  and  sunken,  seldom  and  only  transitorily  flushed  and 
swollen,  except  when  affected  more  or  less  extensively  by  the  vesicular 
eruption.  The  surface  sometimes  moist,  sometimes  dry,  rarely  gives 
to  the  hand  a  sensation  of  febrile  heat,  although  the  temperature  of 
the  body  ranges  above  the  normal  standard.  The  pulse  from  the  out- 
set is  wanting  in  firmness,  and  the  indications  of  defective  tone  increase 
as  the  disease  advances.  The  respiration  exhibits  no  marked  dis- 
turbance, excepting  an  increase  of  rapidity  witnessed  during  accessions 
of  pain  and  restlessness,  and  in  the  advanced  stage  of  the  malady  the 
diminution  dependent  upon  failing  circulation  and  innervation.  The 


DESCRIPTION    OF    THE    DISEASE.  95 

alimentary  canal,  apart  from  the  vomiting,  which  usually  ceases  as  the 
disease  becomes  fully  developed,  presents  little  indication  of  disturb- 
ance. The  tongue  is  as  frequently  clean  and  moist  as  dry,  foul,  and 
discoloured ;  and  the  bowels  may  be  either  costive  or  loose,  the  former, 
perhaps,  more  commonly  than  the  latter.  In  some  outbreaks,  indeed, 
costiveness  has  been  marked  and  almost  general,  but  in  others  diarrhoea 
has  been  prevalent.  The  renal  secretion  is  rarely  much  disturbed. 

As  the  malady  proceeds,  if  it  tends  towards  a  fatal  termination,  the 
spasmodic  symptoms  increase,  the  patient  becomes  comatose,  and  death 
may  occur  either  from  asphyxia  or  exhaustion  in  from  ten  or  twelve 
hours  to  seven  or  eight  days.  If  the  disease  is  prolonged  beyond  this 
period,  various  secondary  lesions  are  apt  to  occur,  especially  certain, 
inflammatory  states  of  the  eyes  and  ears,  the  mischief  in  the  former 
organs  being  shown  by  ulceration  of  the  cornea,  iritis,  and  sometimes 
suppuration  of  the  globe;  in  the  latter  by  less  obvious  structural 
•changes  during  life  except  as  indicated  by  deafness.  Or  there  may  be 
paralysis  affecting  one  half  of  the  body,  or  one  side  of  the  face,  or  one 
of  the  limbs,  or  an  isolated  group  of  muscles.  Or  there  may  be  an 
inflammatory  state,  with  sero-purulent  effusion  into  one  or  more  of  the 
large  joints.  Or,  finally,  the  patient  may  fall  into  a  state  of  marasmus 
and  nervous  exhaustion,  often  protracted  and  not  rarely  fatal.  If  the 
malady  proceed  to  a  favourable  termination  without  any  of  these  se- 
quences, health  may  be  recovered  in  from  three  to  four  weeks.  If  the 
progress  of  the  disorder,  otherwise  favourable,  is  interrupted  by  one 
or  other  complication,  the  period  of  recovery  is  uncertain  and  often 
long  postponed. 

(B)  Fulminant  •  Epidemic  Cerebro-spinal  Meningitis. — In  the  side  rant 
form  of  the  malady  the  onset  is  without  premonition.  The  patient 
suddenly  falls  into  a  state  of  collapse.  The  surface  of  the  body  has 
often  a  cyanotic  aspect,  and  is  cold  and  clammy  to  the  touch,  or  co- 
vered with  a  profuse  perspiration,  the  face  being  not  rarely  shrunk  and 
livid,  and  the  eyes  deep  sunk  as  in  the  algide  stage  of  cholera.  There 
may  be  some  shivering  at  intervals,  more  or  less  pain  of  the  head,  and 
occasional  vomiting,  sometimes  of  a  grumous  black  or  coffee-coloured 
fluid.  Drowsiness,  if  not  present  at  the  outset,  rapidly  supervenes, 
followed  by  or  concurrently  with  delirium.  Coma,  rarely  other  than 
the  precursor  of  death,  quickly  succeeds.  In  the  mean  time,  purpuric 
spots  show  themselves  over  the  surface  of  the  body  generally,  red  or 
purple  and  circumscribed  in  the  beginning,  but  rapidly  becoming 
black,  and  often  extending  their  margins  so  as  to  form  irregular  inky 
blotches,  or  streaks,  or  great  patches;  and  not  unfrequently  several 
of  the  spots  become  gangrenous.  Sometimes  the  purpuric  spots  appear 
contemporaneously  with  the  collapse  at  the  outset  of  the  attack.  The 
respiration  is  preternaturally  slow,  and  the  pulse  (if  it  has  not  been 
absent  at  the  wrist  from  the  beginning)  falls  with  the  progress  of  the 
disease.  The  urine  is  loaded  with  albumen.  Life  may  be  extin- 
guished in  less  thanjfa;e  hours,  or  it  may  be  prolonged  for  two  or  three 
days.  Kecovery  from  this  form  of  epidemic  cerebro-spinal  meningitis 
is  not  unknown,  but  it  is  an  exceedingly  rare  event. 

(c)  Purpuric  Epidemic   Cerebro-spinal  Meningitis. — In  the  purpurio 


96  EPIDEMIC    CEREBRO-SPINAL    MENINGITIS. 

form  of  epidemic  cerebro-spinal  meningitis,  the  symptoms  which  dis- 
tinguish the  simple  and  fulminant  forms  of  the  disease  occur  combined 
together  in  various  proportions,  some  cases  approximating  more  or  less 
closely  to  the  latter,  others,  as  is  most  common,  to  the  former  variety 
of  the  affection.  Thus  concurrently  with  shivering,  intense  headache, 
vomiting,  rachialgia  and  retraction  of  the  head,  there  may  be  de- 
pression of  the  vital  powers  approaching  collapse,  or  collapse  itself, 
with  the  development  of  petechiae,  purpuras,  vibices,  ecchymoses, 
hemorrhage,  from  the  mucous  tracts,  delirium,  coma,  and  rapid  disso- 
lution. In  by  far  the  greater  number  of  cases,  however,  the  disease 
follows  the  course  of  simple  epidemic  cerebro-spinal  meningitis ;  but 
within  twenty-four  hours,  or  from  this  period  to  the  fourth  day,  or 
still  later  in  the  progress  of  the  malady,  petechise  or  purpurae  are 
developed  more  or  less  copiously,  and  occasionally  hemorrhage  occurs 
from  the  mucous  tracts.  This  phase  of  epidemic  cerebro-spinal  menin- 
gitis does  not  appear  to  be  more  fatal  than  the  simple  form  of  the 
disease.  It  has  been  observed  more  commonly  in  the  United  States 
than  on  the  continent  of  Europe,  and  it  was  the  principal  variety  which 
occurred  during  the  recent  outbreak  in  Ireland. 

SPECIAL  SYMPTOMS. — 1.  The  Nervous  System. — Headache  is  almost 
constant,  and  it  is  remarkable  for  its  early  and  persistent  severity.  At 
the  outset  it  is  not  localized  in  any  particular  part  of  the  head.  It 
may  be  referred  to  the  forehead,  the  sides,  the  vertex,  or  the  occiput ; 
or  it  may  be  general.  Later  in  the  disease,  the  occiput  is,  perhaps, 
most  commonly  the  seat  of  pain.  The  intensity  of  the  headache  is, 
as  a  rule,  peculiar.  The  patients  describe  the  pain  as  sharp,  lanci- 
nating, stabbing,  plunging,  tensive,  throbbing,  boring,  or  crushing. 
It  is  so  intolerable  as  to  elicit  groans  and  cries  from  the  sufferer ;  often 
even  during  delirium  or  stupor,  the  exclamations,  the  contraction  of 
the  forehead,  and  the  manner  in  which  the  hands  are  moved  towards 
the  head,  show  that  the  pain  continues.  In  young  children  this  state 
closely  resembles  that  which  is  so  significant  of  tubercular  meningitis. 
The  headache  may  cease  when  the  disease  has  become  fully  developed, 
or,  as  is  probably  more  common,  it  may  persist  throughout  the  whole 
course  of  the  malady  so  long  as  consciousness  remains.  Occasionally, 
indeed,  when  recovery  takes  place,  it  will  continue  far  into  the  period 
of  convalescence. 

Rachialgia  is  rarely  absent.  It  is  sometimes  general  throughout 
the  spinal  region,  but  more  frequently  it  is  limited  to  the  loins,  the 
dorsal  region,  or,  as  is  most  usual,  to  the  posterior  part  of  the  neck. 
Occasionally  the  pain  radiates  from  the  neck  to  the  extremities  and 
walls  of  the  abdominal  and  thoracic  cavities.  In  rare  cases  the  pain 
has  commenced  at  some  point  of  the  peripheral  nervous  system,  and 
spread  thence  to  the  back,  occurring  in  paroxysms.  This  pain  has 
the  same  character  as  the  cephalalgia,  and  the  words  (intolerable, 
atrocious,  tensive,  &c.)  used  to  indicate  the  nature  of  the  latter  may 
be  employed  also  to  describe  the  former.  It  is  augmented  by  move- 
ments, and  its  chief  seat  is  in  the  muscles  of  the  spinal  column. 

The  nuchal  pain  and  its  consequences  constitute  one  of  the  most 


SPECIAL    SYMPTOMS.  97 

characteristic  signs  of  the  disease.  Frequently  at  the  outset  of  the 
malady,  this  pain  is  preceded  by  a  dragging  sensation  at  the  back  of 
the  head.  As  .the  pain  increases  in  intensity,  the  head  is  voluntarily 
thrown  back  to  relieve  all  strain  upon  the  exquisitely  sensitive  mus- 
cles. Or,  in  conjunction  with  the  pain,  spasm  of  the  affected  muscles 
occurs,  and  the  head  is  forcibly  drawn  backwards.  Among  the  popu- 
lar terms  of  the  disease,  those  arising  from  this  symptom  (Nackenstarre, 
Genickkrampf,  Nacksjuka,  &c.)  are  very  prominent.  When  the  rachial- 
gia  is  more  diffused,  and  the  pain  extends  also  to  the  limbs,  adapted 
or  spasmodic  contractions  of  the  trunk  and  lower  extremities  are  apt 
to  occur.  Rachialgia  is  not  present  in  the  sideraht  and  in  severe  cases 
of  the  purpuric  forms  of  the  affection.  It  is  noteworthy  that  pressure 
on  the  spinous  processes,  during  the  most  acute  rachialgia,  rarely 
causes  pain. 

Enteralgia  and  other  Neuralgic  Pains. — Abdominal  pain,  neuralgic 
in  character,  and  more  or  less  closely  linked  to  the  pain  in  the  course 
of  the  spine,  is  not  unfrequent,  and  it  is  often  closely  associated  with 
uncontrollable  vomiting.  In  some  epidemics,  as  in  that  of  18ti5  on 
the  Lower  Vistula,  enteralgia  was  so  common  among  children  seized 
with  cerebro-spinal  meningitis  that.it  gave  rise  to  the  trivial  designation 
"  belly-ache,"  as  one  of  the  popular  names  of  the  disease.  Neuralgic 
pains  in  the  limbs,  referred  to  in  connection  with  rachialgia,  are  less 
common  than  like  pains  along  the  course  of  the  spine  and  in  the  abdo- 
men. 

Increased  Sensitiveness  of  the  Surface  of  the  Body  has  been  described 
ns  frequent  in  several  outbreaks.  During  the  recent  epidemic  in  the 
United  States,  cutaneous  hyperassthesia  is  said  to  have  been  a  charac- 
teristic symptom  of  the  disease  in  its  fully  developed  state.  During 
the  outbreak  on  the  Lower  Vistula,  an  increase  of  cutaneous  sensi- 
tiveness was  also  observed  very  commonly,  but  it  was  not  regarded 
by  Dr.  Burdon  Sanderson  as  a  characteristic  symptom,  but  "a  mere 
consequence  or  interlude  of  pain  :"  being,  in  fact,  an  excessive  tender- 
ness experienced  during  intermissions,  or  after  the  cessation  of  pain. 

Spasm. — Sufficient  care  has  not  always  been  taken  to  discriminate 
between  apparent  and  actual  spasm  in  this  disease.  Tourdes,  in  1813, 
showed  that  the  retraction  of  the  head  and  curvature  of  the  spine  did 
not  in  all. cases  arise  from  a  spasmodic  contraction  of  the  muscles,  but 
that  the  position  was  not  rarely  voluntarily  or  instinctively  assumed 
by  the  patient  as  most  conducive  to  relief  of  the  spinal  pain.  Dr. 
Burdon  Sanderson  confirmed  this  observation  of  Tourdes,  so  far  as 
retraction  of  the  head  was  concerned,  in  1865.  In  the  cases  observed 
by  him,  in  which  the  head  was  apparently  drawn  backwards,  it  was 
practicable  to  extend  the  seemingly  contracted  muscles,  although  the 
effort  gave  rise  to  exquisite  pain  and  instinctive  resistance.  There  was 
not  any  tension  of  the  muscles  except  such  as  arose  from  this  resist- 
ance ;  no  tightness  was  felt  so  long  as  they  were  at  rest.  "  It  was  not 
till  the  neck  was  completely  extended  that  the  muscles  became  hard, 
and  even  then  the  hardness  was  not  for  a  moment  comparable  to  that 
which  is  felt  in  tetanus."  The  position  in  bed  of  the  patients  observed 
by  Burdon  Sanderson  was  that  which  would  produce  the  greatest 
7 


98  EPIDEMIC    CEREBRO-SPINAL    MENINGITIS. 

relaxation  of  painful  groups  of  muscles.  There  can  be  no  doub 
however,  that  spasm  is  a  frequent  accompaniment  of  epidemic  cerebro" 
spinal  meningitis.-  In  the  clonic  form  it  is  witnessed  in  some  cases  as 
transitory  contractions  of  the  facial  muscles,  cramps  of  the  extremities, 
the  convulsive  agitation  and  trembling  referred  to  in  the  general  de- 
scription as  somewhat  like  what  is  observed  in  delirium  tremens,  very 
rarely  in  local  convulsion  of  a  single  limb,  and  still  more  rarely  in 
general  convulsion.  Tonic  spasm  of  the  muscles  of  the  face,  jaws  (tris- 
inus),  and  gullet,  and  of  the  limbs  and  trunk,  may  also  occur,  giving  rise 
to  true  opisthotonos,  emprosthotonos,  or  general  tetanic  rigidity  of  the 
trunk  and  limbs. 

Paralysis  is  not  of  very  common  occurrence  during  the  progress  of 
epidemic  cerebro-spinal  meningitis.  Hemiplegia  has  been  occasionally 
noticed,  and  paralysis  more  or  less  complete  of  one  or  both  extremi- 
ties, upper  and  lower,  of  the  muscles  of  deglutition,  of  articulation, 
and  of  certain  other  associated  groups,  the  latter  chiefly  towards  the 
close  of  the  malady.  The  general  paralysis  noticed  by  some  writers 
was  usually  significant,  and,  indeed,  a  part  of  the  phenomena  of  ap- 
proaching dissolution. 

The  special  senses  do  not  often  manifest  much  change,  except  as  a 
consequence  of  certain  structural  lesions.  Increased,  sometimes  ex- 
quisite, sensitiveness  of  sight  and  hearing  has  occasionally  been  noticed, 
concurrently  with  augmented  sensitiveness  to  other  external  impres- 
sions, especially  towards  the  close  of  the  malady,  when  complete 
consciousness  returns.  Amaurosis  has  also  occurred,  without  apparent 
change  in  the  ocular  apparatus.  It  may  be  noted,  moreover,  of  the 
eye  and  sight,  that  occasionally  there  is  strabismus  and  double-vision. 
The  pupils  may  be  normal  in  aspect  and  action,  or  they  may  present 
various  changes.  They  may  be  dilated  or  contracted,  or  one  dilated 
and  the  other  contracted,  or  they  may  exhibit  curious  alternations  of 
contraction  and  dilatation  under  the  influence  of  the  same  degree  of 
light.  Both  the  eyes  and  the  ears  are  liable  to  undergo  certain  struc- 
tural lesions.  These  consist  in  well-marked  inflammatory  changes, 
commencing  sometimes  in  the  cornea,  sometimes  in  the  deeper  tissues. 
Most  commonly  keratitis  is  set  up,  ending  in  opacity  or  ulceration  ; 
and  if  the  latter,  the  iris  may  become  involved.  Or,  iritis  may  occur 
independently,  with  effusion  of  lymph  or  pus,  and  the  consequences 
thereof  (synechia  posterior  and  distortion  of  the  iris  are  particularly 
noted).  Of  more  deeply-seated  changes  may  be  mentioned  opacity  of 
the  lens  or  of  the  vitreous  humour,  separation  of  the  retina  from  the 
choroid,  purulent  infiltration,  or  atrophy  of  the  eyeball.  The  ear  suffers, 
perhaps,  more  frequently  than  the  eye.  Deafness  is  probably  more 
common  than  defects  of  vision,  and  it  is  largely  dependent  upon  inflam- 
matory changes  set  up  in  the  organ,  and  particularly  affecting  the  lining 
membrane  of  the  vestibule  and  semicircular  canals.  Occasionally,  the 
external  meatus  has  been  affected,  and  a  profuse  purulent  discharge 
flowed  from  it.  These  lesions  of  the  organs  of  sight  and  hearing  may 
occur  either  early  or  late  in  the  course  of  the  disease.  The  sense  of 
smell  very  rarely  suffers.  Its  loss  in  one  nostril  has  been  recorded  in 
a  single  case,  and  this,  perhaps,  dependent  upon  inflammatory  changes 


SPECIAL    SYMPTOMS.  99 

in  the  lining  membrane  of  the  nose,  as  purulent  discharge  from  the 
nostrils  has  occasionally  taken  place. 

Vertigo  is  sometimes  observed  as  an  initial  symptom  of  the  disease 
in  conjunction  with  the  cephalalgia.  Instances  are  recorded  in  which 
the  first  accession  of  the  disease  was  marked  by  severe  giddiness, 
during  which  the  patient  either  staggered  about  like  a  drunken  man, 
or  turned  round  several  times,  and  then  fell. 

Delirium  is  rarely  absent.  It  varies  much  in  character,  and  may 
occur  at  any  period  of  the  seizure.  It  may  be  quiet  or  violent,  transi- 
tory or  more  or  less  persistent.  It  sometimes,  but  rarely,  forms  one 
of  the  symptoms  of  invasion,  when  its  access  is  sudden  and  its  char- 
acter acute.  It  may  supervene  with  violence  after  the  malady  has 
continued  several  hours  or  two  or  three  days.  In  the  acute  form  of 
delirium,  the  patient  is  very  noisy,  and  often  so  violent  as  to  require 
restraint.  Sometimes  it  happens  that  paroxysms  of  furious  excitement 
occur  with  intervals  of  placid  delirium.  Hence  the  necessity  of  great 
watchfulness  in  the  care  of  these  cases.  Most  commonly  the  delirium 
follows  closely  upon  the  initiatory  symptoms,  a"nd  is  aggravated  as  the 
disease  advances.  At  the  beginning,  the  confusion  of  thought  may 
not  be  so  great  but  that  the  patient  can  be  roused  so  as  to  answer 
questions  intelligibly.  Later,  the  incoherence  becomes  much  greater, 
and  is  usually  accompanied  with  considerable  agitation.  Much  differ- 
ence is  observed,  not  only  in  the  degree  of  impairment  of  the  con- 
sciousness, but  also  in  the  periods  of  manifestation  of  the  impairment. 
In  some  cases,  the  delirium  occurs  chiefly  during  the  night ;  in  others, 
and  very  commonly,  it  alternates  with  periods  of  somnolence  or  of 
quietude.  In  the  more  persistent  cases  there  are  usually  exacerbations. 
If  the  disease  tend  to  a  fatal  ending,  the  delirium  is  followed  by  coma ; 
if  to  recovery,  consciousness  is,  as  a  rule,  gradually  recovered:  but, 
at  times,  a  period  of  stupor  intervenes  between  the  subsidence  of  the 
delirium  and  returning  perception.  In  the  slightest  cases  of  the 
malady  the  delirium  may  be  transient  only,  taking  place  at  intervals 
chiefly  during  the  night.  In  the  gravest  cases,  when  death  occurs  in 
a  few  hours,  delirium  is  most  commonly  present.  The  duration  of  the 
delirium  depends  entirely  upon  the  nature  and  duration  of  the  case. 
Instances  are  recorded  in  which  furious  delirium  has  occurred  for 
three  nights  in  succession.  In  other  instances  a  delirious  state  has 
persisted  more  or  less  continuously  for  fifteen  days. 

Stupor  and  Coma. — In  not  a  few  protracted  cases,  delirium  is  fol- 
lowed by  a  prolonged  state  of  stupor,  the  patient  lying  completely 
indifferent  to  external  impressions.'  In  six  cases  observed  by  Dr. 
Burdon  Sanderson,  in  which  there  had  been  violent  delirium  at  the 
outset,  this  state  lasted  from  one  week  to  five  weeks,  the  mean  dura- 
tion of  the  several  cases  being  nineteen  days.  The  observer  remarks, 
however,  that  as  four  of  the  cases  "emerged  from  their  stupor  in  a 
state  of  complete  deafness,  there  was  much  difficulty  in  limiting  accu- 
rately the  period  of  unconsciousness."  Sometimes  the  state  of  stupor 
supervenes  without  the  intervention  of  violent  delirium.  Coma  occurs 
in  nearly  all  fatal  cases,  and  is,  indeed,  generally  the  forerunner  of 
death. 


100  EPIDEMIC    CEREBRO-SPINAL    MENINGITIS. 

2.  The  Digestive  System. — The  uncontrollable  vomiting,  which  is  one 
of  the  characteristic  initiatory  symptoms  of  the  disorder,  is  an  effect  of 
the  cerebral  mischief.  Most  frequent  at  the  beginning  of  the  malady, 
the  vomiting  diminishes  as  the  disease  advances,  occasionally  increasing, 
during  exacerbations.  The  matter  evacuated,  after  the  stomach  has 
been  emptied  of  food,  is  usually  of  a  greenish  or  yellowish  colour  and 
bitter  taste,  and  is  composed  largely  of  bile;  more  rarely  it  is  viscid 
and  white.  Occasionally,  in  the  fulminant  and  purpuric  forms  of  the 
malady,  a  grumous  black  or  coffee  coloured  fluid  is  vomited.  In 
several  outbreaks,  the  vomiting  of  large  quantities  of  Ascarides  lumbri- 
coides  has  been  specially  noted.  The  buccal  cavity  and  tongue  do  not  . 
exhibit  any  particular  signs,  except  in  those  rare  cases  in  which  there 
is  hemorrhage  from  the  gums.  As  a  rule,  the  tongue  is  clean  and 
natural  at  the  outset,  and  its  subsequent  state  depends  upon  the  degree 
of  febrile  excitement  which  may  be  set  up,  or  the  development  of  a 
typhous  state,  when  it  may  become  foul  with  various  well-known  as- 
pects, or  dry  and  black  sordes  accumulating  on  the  teeth.  From  the 
beginning  of  the  attack  the  appetite  for  food  is  destroyed,  whatever 
the  state  of  the  buccal  cavity;  and  sometimes  there  is  much,  at  others 
insatiable  thirst.  The  bowels  are  more  commonly  costive  than  the 
reverse.  In  some  outbreaks  costiveness  has  been  of  general  occurrence. 
Diarrhoea,  late  in  the  disease,  is  not  unfrequently  to  be  attributed  to 
the  previous  administration  of  purgatives,  and  involuntary  stools  are 
usually  one  of  the  accompaniments  of  complete  nervous  and  vital 
prostration. 

8.  The  Urinary  System. — In  the  simple  form  of  epidemic  cerebro- 
spinal  meningitis  the  urine  does  not  exhibit  any  marked  change.  It 
may  be  more  abundant,  and  slight  deposits  of  lithic  acid  may  occur. 
In  the  fulminant,  and  severe  cases  of  the  purpuric  forms,  it  commonly 
(in  the  first-named  form  perhaps  invariably)  contains  albumen,  some- 
times in  large  amount,  and  occasionally  cylindrical  casts  and  blood- 
corpuscles.  Retention  or  incontinence  of  urine  has  occurred  in  the 
progress  of  the  disease. 

4«  The  Respiratory  System. — In  all  the  graver  cases  the  respiration 
is  more  or  less  altered.  It  is  sighing,  laboured,  or  interrupted.  Dr. 
Burdon  Sanderson  writes  of  the  outbreak  on  the  Lower  Vistula:  "In 
all  severe  cases,  whether  of  children  or  adults,  the  breathing  was 
embarrassed  in  proportion  to  the  general  gravity  of  the  symptoms. 
This  embarrassment  was  marked  by  a  slow,  laboured  inspiration, 
followed  by  quick  respiration  and  a  long  pause,  that  condition  of 
breathing  which  is  so  frequently  observed  in  continued  fever  (espe- 
cially typhoid),  and  is  often  called  suspirious.  In  all  the  fatal  cases 
which  came  under  my  notice,  the  most  prominent  symptoms  which 
preceded  death  were  those  which  indicate  impairment  and  perversion 
of  the  respiratory  function.  As  the  breathing  became  more  hurried 
and  difficult,  the  general  depression  became  more  intense,  the  pulse 
became  weaker  and  quicker,  and  the  temperature  of  the  skin  more 
elevated."  Dr.  S.  Gordon  records  a  case,  fatal  in  less  than  five  hours, 
in  which  the  respirations  rapidly  fell  to  nine  per  minute,  the  pulse  at 
the  time  being  120. 


SPECIAL  r.S/?MPTOMS.  101 

F  f-      •  :  '^  f-  TIJ  if 

5.  The  Circulatory  System. — The  'cardinal  point  with  respect  to  'the' 

circulation,  as  indicated  by  the  radial  pulse,  is  defect  of  arterial  teuton. 
This  has  been  common  to  all  epidemics,  with  hardly  an  exception; 
and  the  exceptional  instances  have  probably  been  more  apparent  than 
real.  The  frequency  of  the  pulse  does  not  admit  of  general  statement. 
It  has  a  wide  range.  In  the  epidemic  on  the  Lower  Vistula,  the  pulse 
in  six  adult  cases  observed  by  Dr.  Burdon  Sanderson  varied  from  56 
to  98,  the  average  beats  being  85.  In  several  cases  noted  by  the  same 
observer  "its  frequency  varied  considerably  from  day  to  day,  without 
apparent  relation  to  the  condition  of  the  patient  in  other  respects." 
During  the  Philadelphia  outbreak  of  1866,  in  98  cases  observed  by 
Dr.  W.  H.  H.  Githens,  the  pulse  varied  from  the  normal  beat  to  150  per 
minute  in  uncomplicated  cases,  and  reached  as  high  as  160  in  two 
cases,  in  puerperal  women.  "  It  was  in  all  very  weak,  with  a  dichrotic 
tendency,  sometimes  entirely  imperceptible  in  the  radial  artery,  and 
always  interrupted  by  slight  pressure." 

6.  The  Cutaneous  System — In  respect  of  dryness  or  moisture  or 
feeling  to  the  touch,  the  skin  presents  no  constant  condition  ;  but  in 

•numerous  cases  it  is  the  seat  of  various  forms  of  eruption  of  remark- 
able interest.  The  extent  of  prevalence  or  predominance  of  one  or 
other  of  these  different  forms  of  eruption  has  varied  considerably  in 
the  numerous  recorded  outbreaks.  In  the  epidemics  which  have  oc- 
curred in  the  United  States,  petechice  have  been  so  common  as  to  have 
given  rise  to  the  popular  name  of  the  disease  (spotted  fever),  and  to 
have  induced  Dr.  G.  B.  Wood,  Professor  of  the  Theory  and  Practice 
of  Medicine  in  the  University  of'  Pennsylvania,  to  adopt  as  the  tech- 
nical designation  of  the  disease  the  term  petechial  fever.  During  the  re- 
cent outbreak  in  Ireland  (1866-67), purpura  was  the  predominant  form 
of  eruption,  and  Professor  Stokes  proposed  to  designate  the  malady  ma- 
lignant purpuric  fever /  other  observers  also  suggesting  terms  founded 
upon  this  character.  In  the  outbreak  on  the  Lower  Vistula  (1865), 
an  herpetie  eruption  was  most  common.  In  all  the  greater  outbreaks, 
each  form  of  eruption  mentioned  in  the  definition  of 'the  disease  has 
been  observed ;  but  the  proportion  of  cases  in  which  one  or  other 
form  of  eruption  has  prevailed  has  varied  greatly  in  each  outbreak. 
In  some  of  the  earlier  outbreaks  in  the  tFnited  States  few  cases  oc- 
curred in  which  a  petechial  eruption  was  not  noted.  Of  98  cases 
admitted  into^the  Philadelphia  Hospital  (Blockley)  in  1866,  36  had 
petechiaa ;  13  mixed  petechiae  arid  erythema;  9  erythema  and  urti- 
caria; 3  indistinct  petechial  mottling,  and  37  no  eruption  at  all 
(GITHENS).  In  the  outbreak  on  the  Lower  Vistula  the  proportion  of 
cases  exhibiting  an  eruption  was  comparatively  small;  in  the  recent 
outbreak  in  Ireland,  large.  The  forms  of  eruption  observed  are  as 
follows:  (a)  Vesicles.  A  vesicular  eruption  (eczema,  HlRSCH),  some- 
times herpetic  in  character,  chiefly  appearing  in  the  vicinity  of  the 
lips,  but  occasionally  extending  over  the  sides  of  the  face,  diffused 
more  or  less  on  the  trunk,  or  showing  itself  in  patches  on  the  limbs. 
This  symptom  has  occasionally  taken  the  form  of  shingles.  It  is  most 
commonly  noticed  in  the  simple  form  of  the  disease,  but  it  may  take 
place  in  either  of  the  other  forms,  and  when  associated  with  purpura, 


102  EPIDEMIC    CEREBRO-SPINAL    MENINGITIS. 

the  vesicles  may  be  flattened  and  rest  upon  a  livid  base,  presenting  a 
horrible  aspect.  This  form  of  eruption  may  appear  as  early  as  the 
second  day.  (b)  Purpura.  1.  True  petechice.  2.  Purpuric  spots,  vary- 
ing in  size  from  a  split  pea  to  half-a-crown,  with  more  or  less  extensive 
effusions  of  blood,  or  of  its  colouring  matter,  into  the  cutis  (vibices, 
ecchymoses).  The  spots  have  sometimes  a  regular,  sometimes  an  irre- 
gular, even  a  ragged,  outline.  Their  size  may  remain  fixed  from  the 
time  of  their  first  appearance,  or  it  may  increase  largely  and  rapidly. 
They  may  be  of  a  light  or  dark  red  colour  at  the  outset,  subsequently 
becoming  purple  and  black;  or,  as  is  most  common,  they  may  from 
the  beginning  be  dark  purple  or  black,  their  blackness  being  often 
fittingly  likened  to  that  of  ink — the  eruption  resembling  "spots"  or 
"splashes"  of  that  fluid.  They  may  appear  on  the  trunk  or  limbs 
only,  or  they  may  be  scattered  copiously  over  the  whole  surface  of  the 
body,  including  the  face.  The  purpuric  spots  are  frequently  hard  to 
the  touch,  the  margin  being  defined,  and  giving  the  impression  to  the 
fingers  of  being  raised  above  the  surface:  sometimes  a  vesicle  forms 
above  several  of  the  spots,  and  gangrene  of  the  adjacent  tissue  takes 
place.  Dr.  S.  Gordon  writes  of  the  recent  epidemic  in  Ireland  :  "  Many  , 
cases  are  accompanied  by  a  distinct  eruption,  which  comes  out  with 
great  rapidity;  is  found  over  all  parts  of  the  body,  but  chiefly  op  the 
lower  extremities;  is  of  a  very  dark  colour,  sometimes  very  deep 
brown,  or  purple,  or  even  black.  The  spots  are  of  various  sizes  and 
shapes,  some  small  and  round,  others  large  and  irregular;  some  ap- 
pear like  large  spots  of  very  black  purpura,  only  more  mottled  and 
more  irregular  in  colour  and  shape;  others  are  more  confined,  and 
raised  above  the  level  of  the  skin,  consisting  in  effusion  into  its  sub- 
stance: many  patients  die  in  this  stage,  but  in  some  the  disease  pro- 
gresses, and  these  spots  are  absorbed,  leaving  a  yellowish  mark  under 
the  cuticle;  or- they  pass  into  superficial  gangrene,  which  was  spread- 
ing at  the  time  of  the  patient's  death,  or  is  healed  with  loss  of  substance." 
Purpuric  spots  are  sometimes,  although  rarely,  one  of  the  earliest 
signs  of  the  fulminant  and  purpuric  forms  of  the  malady ;  or  they 
may  occur  at  any  period  during  the  more  advanced  stages.  Usually 
they  appear  at  some  period  during  the  first  four  days,  chiefly  perhaps 
during  the  first  or  second  day.  Sometimes,  with  or  without  the  pur- 
puric spots,  there  is  a  cyanosed  aspect  of  the  skin,  or  a  peculiar  livid 
mottling.  During  recovery  the  pupuric  spots  gradually  lose  their  defi- 
nition and  fade  away,  passing  through  the  different  stages  of  colour 
which  mark  a  healing  bruise,  (c)  Roseola,  erythema,  &c.  Rose-coloured 
spots  or  patches  are  occasionally  observed  ;  also  erythema,  more  or  less 
diffused,  a  rubeoloid  eruption,  and  urticaria. 

7.  Temperature. — The  temperature  of  the  body,  as  marked  in  the 
axilla,  is  heightened  in  every  case ;  except,  perhaps,  those  accompanied 
by  profound  collapse  from  the  beginning.  In  many  cases  this  height- 
ened temperature  is  found  contemporaneously  with  the  invasion  of 
the  disease;  in  other  cases  there  is  no  conspicuous  increment  until 
the  second  or  third  day.  When  the  characteristic  symptoms  of  the 
malady  are  developed,  the  temperature  rarely  falls  below  100°  Fahr., 
and,  as  the  disease  advances,  it  ranges  in  adults  from  100°  to  105°,  in 


COMPLICATIONS — DURATION — TERMINATION.  103 

children  sometimes  even  higher.  There  is  no  constant  or  conspicuous 
difference  between  the  morning  and  evening  temperature,  as  in  typhus 
and  typhoid.  A  steady  fall  marks  the  decline  of  the  disease  and  the 
approach  of  recovery  ;  a  rapid  fall  ushers  in  collapse  or  death. 

COMPLICATIONS. — The  course  of  the  disease  is  liable  to  be  modified 
by  certain  complications.  Of  these  the  chief  are  as  follows:  (a)  Tho- 
racic, inflammations:  pleurisy,  pneumonia,  bronchitis,  or  pericarditis. 
Dr.  S.  Gordon  describes  oedema  of  the  lungs  and  diffuse  pulmonary 
apoplexy,  (b)  Swelling  or  inflammation  of  the  parotids,  (c)  Inflam- 
mation of  the  large  joints,  marked  by  swelling  and  pain,  and  sometimes 
endigg  in  sero-purulent  effusion.  This  complication,  in  its  less  aggra- 
vated form,  has  been  described  by  some  writers  as  rheumatic,  (d)  An 
Inflammatory  condition  of  the  eyes  and  ears,  as  already  noted,  (e) 
Bed-sores.  Large,  deep,  black  sloughs  occurred  in  four  cases  out  of 
161  treated  in  the  Philadelphia  Hospital  in  1866.  (/)  The  course  of 
the  disease  has  also  been  complicated  by  the  supervention  of  other 
maladies,  namely,  (1)  Intermittent  fever,  or  certain  paroxysmal  phe- 
nomena simulating  malarious  poisoning:  a  complication  which  has 
led  to  erroneous  notions  of  the  nature  of  the  disease.  In  the  outbreak 
on  the  Lower  Vistula  cases  were  observed  in  which  regular  or  irre- 
gular intermissions  took  place  that  could  not  be  assigned  to  a  malarious 
origin.  (2)  Typhoid  fever,  the  two  diseases  prevailing  simultaneously 
jn  the  same  district.  The  symptoms  of  both  diseases,  more  or  less 
modified,  pursue  their  course  together,  and  the  characteristic  lesions  of 
typhoid  as  well  as  of  epidemic  cerebro-spinal  meningitis  are  discovered 
after  death.  (3)  Measles  and  scarlet  fever.  (4)  Cholera  (LEVY)*, 

DURATION. — In  the  outbreak  on  the  Lower  Vistula,  the  most  acute 
cases  terminated  fatally  in  from  12  to  72  hours.  Cases  of  less  intensity, 
but  in  which  the  patient  eventually  died  in  a  typhous  state,  lived  from 
8  to  14  days,  the  characteristic  symptoms  of  the  disease  persisting  to 
the  end.  In  the  more  protracted,  or  complicated  cases,  from  5  to  8 
weeks  have  passed  before  a  patient  entered  upon  convalescence,  and 
death  has  taken  place  in  the  6th  or  7th  week.  Of  the  cases  observed 
in  the  Philadelphia  Hospital  (1866).  the  duration  of  those  which  ended 
fatally  was  from  48  hours  to  11  days;  of  those  which  recovered,  from 
20  to  30  days,  the  acute  symptoms  rarely  exceeding  a  fortnight.  In 
the  recent  outbreak  in  Ireland,  Dr.  S.  Gordon  has  reported  a  well- 
marked  case  which  ended  fatally  after  less  than  five  hours'  duration. 
A  large  proportion  of  the  fatal  cases  in  that  outbreak  died  in  from  10 
to  48  hours;  in  other  cases  the  fatal  ending  did  not  occur  until  the 
end  of  the  second  and  during  the  course  of  the  third  week  of  the  dis- 
ease. The  duration  of  the  disease,  as  shown  by  death,  may  be  clearly 
stated ;  as  marked  by  the  beginning  of  convalescence,  it  does  not  admit 
of  definite  description.  Moreover,  convalescence  is  often  very  pro- 
tracted. The  course  of  the  disease  towards  recovery  is  sometimes 
interrupted  by  relapses. 

TERMINATION: — The  disease  terminates  after  a  longer  or  shorter 
period  of  convalescence  in  health ;  or  it  entails  during  convalescence 


lOi  EPIDEMIC    CEREBRO-SPINAL    MENINGITIS. 

a  series  of  physical  or  mental  ills;  or  it  ends  in  death.  The  rate  of 
mortality  of  the  disease  is  the  measure  of  probable  recovery.  It  varies 
much  in  different  outbreaks,  but  is  at  all  times  formidable.  Among 
the  cases  observed  in  the  Philadelphia  Hospital  in  1866  the  mortality 
was  33  per  cent.;  in  the  Hardwicke  Hospital,  Dublin,  the  same  year, 
the  mortality  was  80  per  cent.  Dr  Stille'  remarks  that,  "while  ten 
epidemics  in  various  places,  occurring  between  1838  and  1848,  pre- 
sented an  average  mortality  of  70  per  cent.,  a  similar  number  occurring 
during  the  decade  from  1855  to  1865  give  an  average  mortality  of 
about  30  per  cent.  This  remarkable  fact  would  seem  to  indicate  a 
gradual  decline  of  power  in  the  epidemic."  The  minimum  rate  of 
mortality  recorded  is  20  per  cent.  The  proportion  of  fatal  cases  is 
greatest,  and  the  duration  of  these  cases  least,  at  the  commencement 
of  an  outbreak.  The  sequelae  which  interfere  with  the  restoration  of 
the  patient  to  perfect . health  are:  Deafness;  impaired  vision  from 
structural  changes  in  one  or  both  eyes;  paralysis  of  one  or  more  limbs 
or  of  certain  groups  of  muscles;  impaired  memory;  carbuncles,  and 
boils.  Dr.  S.  Gordon  describes  a  case  in  which  the  patient  "  recovered 
from  all  the  acute  symptoms,  but  gradually  passed  into  a  state  of  almost 
organic  life.  He  ate,  drank,  and  slept  well ;  he  passed  solid  feces  and 
urine  without  giving  any.  notice,  yet,  evidently,  not  unconsciously; 
he  was  excessively  emaciated,  and  there  was  a  peculiar  mouse-like 
smell  from  him;  he  seemed  to  understand  what  was  said  to  him,  but 
he  could  not  answer;  he  never  called  for  anything;  his  breathing  was 
rather  slow;  his  pulse  120;  his  heart  acting  with  a  peculiar  strong 
jerking  motion;  his.  eye  was  quite  well,  as  also  his  knee  [he  had  suf- 
fered from  ulceration  of  the  right  cornea  and  immense  effusion  into 
the  right  knee-joint]  ;  he  could  draw  his  legs  and  arms  up  to  him  ; 
but  he  could  not  use  his  hands  at  all."  Such  was  the  condition  of  the 
patient  fifty-eight  days  after  the  invasion  of  the  disease. 

MODE  OF  DEATH.— Death  chiefly  occurs  from  (a)  asphyxia,  caused 
by  damage  to  the  respiratory  nerve  centres;  (b)  from  asthenia;  and 
(c)  in  some  of  the  fulminant  cases  probably  from  necrastnia,  so  profound 
are  the  changes  observed  in  the  blood. 

DIAGNOSIS. — In  some  instances  the  disease  approximates  in  certain 
symptoms  to  typhus  or  typhoid,  and  it  occasionally  prevails  contem- 
poraneously with  both  maladies.  But  the  history  of  the  development 
and  progress  of  the  disease,  with  the  absence  of  characteristic  eruption, 
will  usually  clear  up  any  doubt.  From  sporadic  spinal  meningitis  the 
disease  is  distinguished  by  its  epidemicity,  the  almost  constant  concur- 
rence of  cerebral  disorder,  the  tendency  to  cutaneous  eruptions,  the 
great  mortality,  and  the  rareness  of  protracted  or  permanent  paralysis 
or  contraction  of  the  lower  limbs.  The  distinction  between  the  disease 
and  cerebral  meningitis  is  less  defined  as  to  particular  symptoms,  espe- 
cially in  children,  but  the  mode  of  development  of  the  malady  will 
rarely  leave  much  room  for  doubt  during  an  outbreak.  Tetanus  (so 
called  idiopathic),  with  which  it  is  suggested  that  epidemic  cerebro- 
spinal  meningitis  may,  under  certain  states  of  spasm,  be  confounded, 
never  manifests  the  early  grave  cerebral  symptoms  which  occur  in  the 


PROGNOSIS — MORBID.  ANATOMY.  105 

latter  disease.  The  tetanoid  contraction  also,  observed  in  epidemic 
cerebro-spinal  meningitis  is  rarely,  if  ever,  as  in  tetanus,  aggravated 
by  sudden  and  painful  spasms.  The  grouping  of  the  symptoms  in  the 
two  diseases  is,  moreover,  altogether  different.  Dr.  S.  Gordon  points 
out  the  possibility  of  confounding  the  purpuric  form  of  epidemic  cere- 
bro-spihal  meningitis  with  malignant  measles,  which  rnalady  has  often 
prevailed  at  the  same  time.  The  last-named  disease  may  resemble  the 
fulminant  form  of  the  first-named  in  several  respects  particularly  the 
rapidity  of  development,  and  dark  colour  of  the  eruption,  and  the  rapid 
appearance  of  petechiae ;  also  in  the  sudden  and  often  extreme  collapse 
which  accompanies  the  invasion  of  the  affection.  But  the  eruption  of 
measles  rarely  loses  its  characteristic  form,  and*  the  affection  of  the 
respiratory  passages  is  commonly  present,  while  purpuric  spots  and 
patches  are  seldom  observed.  Dr.  S.  Gordon  also  states  that  he  has 
known  several  cases  in  which  the  earlier  symptoms  of  epidemic  cere- 
bro-spinal meningitis  in  young  excitable  females  have  been  mistaken 
for  hysteria. 

PROGNOSIS. — At  the  best,  the  prognosis  of  the  disease  is  very  grave. 
The  mortality  may  be  equally  great  in  each  of  the  three  varieties,  and 
petechia3  and  purpura  do  not  necessarily  indicate  an  aggravated  degree 
of  danger  as  in  other  acute  diseases.  In  50  per  cent,  of  the  cases 
recorded  by  Dr.  Githens,  in  one  of  the  least  fatal  outbreaks  knowny 
petechiae  were  present,  and  it  is  especially  remarked  that  neither  this 
nor  any  other  form  of  eruption  had  "  any  reference  to  the  prognosis." 
But  when  hemorrhage  into  the  cutis  is  extensive,  either  from  the 
number  or  the  size  of  the  spots,  and  is  accompanied  by  marked  signs 
of  vital  prostration,  it  indicates  aa  extremity  of  danger,  although  not 
a  certainty  of  death.  The  disease  is  more  fatal  among  infants  and 
young  children  than  among  youths  and  adults  in  the  prime  of  life; 
but,  in  some  outbreaks,  the  latter  have  suffered  most.  After  thirty 
years  of  age  it  becomes  more  dangerous.  Life  is  most  endangered  in 
the  earlier  days  of  the  disease,  particularly  during  the  first  five.  But 
danger  is  present  at  all  periods  of  the  malady,  and  the  convalescent  is 
not  entirely  safe  until  health  is  fully  restored.  Of  the  special  symptoms, 
whether  of  excitement  or  depression,  the  rules  of  prognosis  hold  good 
which  apply  to  other  highly  fatal  acute  maladies. 

MORBID  ANATOMY. — The  essential  anatomical  characteristics  of  the 
disease,  found  after  death,  are  hypersemia,  often  intense,  of  the  pia 
mater  of  the  brain,  and  spinal  cord;  with  more  or  less  copious  sub- 
arachnoid,  and  interstitial  effusion  into  the  meshes  of  the  congested 
pia  mater,  either  of  serurn,  or  of  a  transparent,  gelatinous  material,  or 
of  purulent  matter  :  the  latter  more  frequently  than  either  of  the  two 
former.  The  purulent  effusion  is  of  greenish  or  yellowish  colour,  and 
is  sometimes  flaky.  It  has  been  found  in  a  case  in  which  death  took 
place  in  less  than  five  hours  from  the  invasion  of  the  disease  (S.  GOR- 
DON). The  extent  to  which  these  appearances  are  observed  and  the 
amount  of  effusion  varies  greatly  in  different  cases.  No  part  of  the 
encephalic  or  spinal  pia  mater  and  arachnoid  may  be  free,  or  certain 
portions  alone  may  be 'affected;  but  effusion  is  limited  to  the  sub- 


106  EPIDEMIC    CEREBRO-SPINAL    MENINGITIS. 

arachnoid  space,  and  does  not  occur  into  the  arachnoid  cavity.  Under 
the  microscope,  according  to  Dr.  Burdon  Sanderson,  the  gelatinous 
material  is  "  always  found  to  consist  of  cell-like  bodies,  either  adhering 
to  each  other  so  closely  that  they  could  not  be  completely  separated, 
or  imbedded  in  a  transparent  interstitial  substance,  while  the  sero- 
purulent  liquid  which  occupied  the  spinal  sub-arachnoid  space,  and  in 
some  cases  the  ventricles,  exhibited  corpuscles  and  granules  floating 
freely.  The  cell-like  bodies,  although  in  general  resembling  pus  cor- 
puscles, did  not  present  that  uniformity  of  size  and  character  which  is 
met  with  in  normal  pus.  They  were  usually,  but  not  always,  of  regu- 
lar circular  contour,  and  varied  in  diameter  from  ^^th  to  T2V5ta  °f 
an  inch.  Occasionally  they  exhibited  the  appearance  of  an  external 
cell-membrane,  but  in  most  instances  this  could  not  be  made  out  even 
in  perfectly  fresh  exudations — as,  e.  g.,  in  those  cases  which  were  exa- 
mined as  early  as  eight  hours  after  death.  They  invariably  contained 
numerous  granules,  some  of.  which  were  cleared  away  on  the  addition 
of  acetic  acid.  Those  which  remained  were  highly  refractive,  but 
did  not  assume  any  special  form  of  arrangement.  The  interstitial 
substance  was  beset  with  granules,  some  of  which  were  albuminous, 
others  fatty.  It  was  most  abundant  and  distinct  on  the  surface  of  the 
spinal  arachnoid,  where-  it  infiltrated  the  fine  connecting  tissue  and 
minute  bloodvessels  of  the  pia  mater." 

For  the  rest,  the  nervous  system  of  the  brain  and  spinal  cord  is 
usually  gorged  with  blood,  except  death  has  taken  place  late  in  the 
course  of  the  disease.  The  visceral  arachnoid  is  frequently  thickened 
and  opaque.  Softening  of  some  portion  of  the  spinal  cord  has  some- 
times been  observed;  and  Mr.  J.  Simon  thinks  that,  "for  practical 
purposes,  the  state  of  the  covering  membranes  of  the  nervous  centres 
may  be  regarded  as  a  mere  index  of  changes  more  or  less  distinctive, 
which  those  centres  in  their  own  intimate  composition  have  at  the 
same  time  undergone ;  and  hence  it  is  that  the  essential  phenomena 
of  the  disease  during  life  consist  in  disturbances,  more  or  less  grave, 
of  the  functions  of  these  all-important  organs." 

In  fatal  cases  of  the  simple  and  purpuric  forms  of  epidemic  cerebro- 
spinal  meningitis  the  characteristic  anatomical  lesions  are  almost  in- 
variably found.  In  the  fulminant  form  of  the  disease  they  are  often 
absent.  The  cases  in  which  there  is  no  indication  of  morbid  change 
in  the  nervous  centres  are  exceedingly  few.  It  has  been  suggested 
that  in  these  cases  death  has  occurred  so  rapidly  that  there  was  insuf- 
ficient time  for  the  formation  of  a  structural  lesion.  In  connection 
with  this  explanation  the  case  recorded  by  Dr.  S.  Gordon  must  be 
borne  in  mind,  in  which  purulent  effusion  was  found,  although  the 
whole  duration  of  the  attack  was  under  Jive  hours.  Practically  the 
apparent  absence  of  characteristic  anatomical  change  in  the  nervous 
centres  in  certain  rare  cases  of  epidemic  cerebro-spinal  meningitis  is  a 
phenomenon  analogous  to  that  which  sometimes  occurs  in  rapidly  fatal 
cases  of  malarious,  variolous,  and  scarlatinous  poisoning,  in  which  the 
characteristic  eruptions  or  lesions  of  the  diseases  have  not  been  de- 
veloped. 

No  lesions  peculiar  to  epidemic  cerebro-spinal  meningitis  are  found 


HISTORY    AND    GEOGRAPHICAL    DISTRIBUTION.  107 

in  other  organs  of  the  body.  Such  lesions  as  occur  elsewhere  than 
in  the  coverings  of  the  brain  and  spinal  cord  usually  have  a  definite 
relation  to  the  thoracic,  abdominal,  or  genito  urinary  complications 
which  may  have  happened  during  the  progress  of  the  malady.  In  the 
fatal  cases  of  the  purpuric  form  of  the  affection  recorded  by  Dr.  S. 
Gordon,  and  other  writers,  an  excessive  fluidity  of  the  blood  was 
noted. 

HISTORY  AND  GEOGRAPHICAL  DISTRIBUTION. — The  history  of  epi- 
demic cerebro-spinal  meningitis  dates  only  from  th#  fourth  decennium. 
of  the  present  century.  At  that  .period  the  disease  was  for  the  first 
time,  clearly  distinguished  as  an  independent  malady ;  and  with  the 
light  then  obtained,  outbreaks  which  had  occurred  earlier  in  the  cen- 
tury, in  various  localities  of  both  the  Eastern  and  Western  hemis- 
pheres, and  had  been  recorded  under  other  names,  were  recognized 
as  of  similar  character.  It  has  been  sought,  indeed,  to  show  that  epi- 
demic cerebro-spinal  meningitis  has  probably  existed  from  remote 
periods  (TouRDES,  BOUDIN).  The  probability  may  be  admitted,  for 
the  first  recognition  of  a  malady  as  an  independent  affection  does  not 
necessarily  imply  that  the  malady  is  new. 

In  1837  epidemic  cerebro-spinal  meningitis  broke  out  in  the  south- 
west of  France,  and  prevailed  in  various  localities  of  the  district  in- 
tervening between  Bayonne  and  La  Rochelle,  and  along  the  whole 
line  of  the  Pyrenean  frontier.  Dax,  Bordeaux,  Auch,  Foix,  Narbonne, 
and  Perpignan  suffered,  as  well  as  the  two  cities  previously  named. 
The  disease,  according  to  Boudin,  at  the  commencement  and  during 
the  continuance  of  this  outbreak,  chiefly  showed  itself  among  troops 
in  garrison.  During  1837  and  1838  the  garrisons  of  Bayonne,  Dax, 
Bordeaux,  Rochefort,  and  La  Rochelle  suffered.  From  1838  to  1841 
the  disease  was  prevalent  among  the  garrisons  of  southeastern  France, 
particularly  those  of  the  valley  of  the  Rhone.  Thus  it  broke  out  at 
Toulon,  Marseilles,  Aigues-Mortes,  Nismes,  Avignon,  and  Pont-Saint- 
Esprit.  In  the  course  of  the  four  years,  1839-40-41-42,  the  malady 
appeared  in  succession  among  the  troops  occupying  the  fortresses  of 
Strasburg,  Schelestadt,  Colmar,  Nancy,  Metz,  and  Givet.  From  1839 
to  1842  it  prevailed  among  the  forces  at  Versailles,  Saint-Cloud,  Ram- 
bouillet,  and  Chartres.  Those  stationed  along  the  coast  of  Brittany, 
at  Brest,  L'Orient,  Nantes,  and  Ancenis,  suffered  in  1841 ;  and  during 
1840  and  1841  the  disease  manifested  itself  among  divers  detachments 
of  a  regiment  scattered  at  Laval,  Le  Mans,  Chateau-Gontier,  Tours, 
and  Poitiers.  It  was  during  the  outbreak  of  which  the  most  remarka- 
ble episode  is  thus  sketched  by  Boudin  that  a  scientific  knowledge  of 
epidemic  cerebro  spinal  meningitis  was  first  obtained.  From  1837  to 
1848  inclusive,  forty-seven  outbreaks  of  the  malady  were  recorded  in 
thirty-six  of  the  eighty-six  departments  into  which  France  was  then 
divided.  These  outbreaks  were  distributed  in  the  departments  of  the 
Loire,  Rhone,  Bouches-du^Rhone,  Bus-Rhin,  Seine,  Seine-et  Oise, 
Landes,  Basses- Pyrenees,  Charente  Inferieure,  Gard,  Vaucluse,  Var, 
Moselle,  and  Loiret.  The  three  first-named  departments  suffered  most. 
In  1840,  the  disease  appeared  in  Naples  and  prevailed  in  the  Papal 


108  EPIDEMIC    CEREBRO-SPINAL    MENINGITIS. 

States.  The  same  year  it  broke  out  among  the  French  garrison  at 
Douera,  Algeria,  and  during  the  next  seven  years  it  attacked  numerous 
towns  and  localities  of  the  province,  affecting  the  civil  population, 
both  European  and  native,  as  well  as  the  military.  In  1841  an  out- 
break of  the  disease  took  place  among  the  civil  population  of  Gibraltar ; 
and  in  1846  the  malady  showed  itself  slightly  in  Ireland  among  the 
inmates  of  the  Rathdown,  South  Dublin,  and  Belfast  workhouses,  and 
several  cases  occurred  among  the  population  of  Dublin.  During  1849 
and  1850  the  disease  was  prevalent  to  some  extent  among  the  French 
troops  in  Italy,  and^n  the  last-named  years  several  localities  of  France 
suffered  from  it.  Epidemic  cerebro-spinal  meningitis  appeared  in 
Denmark  in  1841,  and  prevailed  in  that  country  until  1818.  The 
disease  was  first  noticed  in  Sweden  in  1854,  this  country  again  suf- 
fering from  it  in  1861.  In  Norway  the  malady  broke  out  in  1859, 
and  it  has  prevailed  in  that  country  more  or  less  since  that  year. 
During  I860  the  disease  was  prevalent  in  Holland ;  and  the  same 
year  it  was  widely  spread  in  Portugal.  In  1868,  1864,  and  1865  an 
extensive  outbreak  occurred  in  North  Germany;  and  in  1866  the 
malady  broke  out  in  Dublin  and  elsewhere  in  Ireland. 

In  the  United  States  (where  the  disease  may  be  traced  back  to  the 
commencement  of  the  century),  epidemic  cerebro-spinal  meningitis 
became  prevalent  about  the  same  time  that  it  exhibited  great  activity 
in  Europe.  From  1842  to  1850  inclusive,  a  series  of  outbreaks  took 
place  in  the  States  of  Kentucky,  Tennessee,  South  Illinois,  Mississippi, 
Arkansas,  Alabama,  Pennsylvania,  Massachusetts,  New  York,  and 
North  Carolina.  After  this  period  there  would  appear  to  have  been 
an  interval  of  comparative  inactivity.  In  1861  the  disease  broke  out 
in  North  and  Central  Missouri,  and  from  that  time  to  the  present  it 
has  prevailed,  more  or  less  extensively,  in  almost  all,  if  not  all,  the 
States  of  the  Union,  with  the  exception,  perhaps,  of  the  Pacific  States. 
In  1862  outbreaks  were  recorded  in  Connecticut,  Kentucky,  Indiana, 
and  Tennessee;  in  18H3,  in  Rhode  Island;  in  1864,  in  Pennsylvania, 
Ohio,  Illinois,  New  York,  Maryland,  Massachusetts,  and  Vermont ; 
and  in  1865  in  North  Carolina  and  other  Southern  States.  During 
the  past  year  the  disease  was  active  in  several  States. 

It  must  be  borne  in  mind  that  these  historical  notes  very  imper- 
fectly represent  the  probable  prevalence  and  geographical  distribution 
of  the  disease,  They  simply  include  a  brief  summary  of  outbreaks 
which  have  come  under  the  notice  of  thoughtful  observers  who  have 
published  their  observations.  .  The  history  of  the  malady  in  the 
British  Islands  is,  perhaps,  less  liable  to  error  from  this  source.  The 
earliest  recorded  outbreak  of  the  disease  occurred  in  Ireland  during 
the  early  months  of  1846.  It  broke  out  to  a  very  limited  extent 
among  the  boys  living  in  the  Rathdown  Union,  South  Dublin,  and 
Belfast  workhouses;  and  two  cases,  both  females,  one  aged  17  years, 
the  other  36  years,  were  admitted  into  the  Hardwicke  Hospital  Dublin.1 
Prior  to  this  outbreak,  there  is  not  any  trustworthy  history  of  the 
presence  of  epidemic  cerebro-spinal  meningitis  in  the  British  Islands. 

1  Dr.  Robt.  Mayne,  Dublin  Quarterly  Journal  of  Medical  Science,  1846,  vol.  ii.  p.  95. 


HISTORY    AND    GEOGRAPHICAL    DISTRIBUTION.  109 

It  is  not  improbable,  however,  that  the  disease  existed  at  Blackaton,  in 
Devonshire,  in  1807  j1  and  at  Sunderland  in  1830.2  Dr.  B.  W. 
Richardson  saw  an  unquestionable  case  at'Mortlake,  Surrey,  in  1843.3 
From  the  time  of  the  outbreak  in  1846,  cases  of  a  similar  malady  were 
occasionally  observed  in  Dublin,  until  the  latter  half  of  1850,  when 
they  became  more  common.4  There  is  no  further  notice  of  epidemic 
cerebro  spinal  meningitis  in  Ireland  until  the  year  1865,  when  cases 
began  to  be  again  observed  in  Dublin.4  A  case  of  cerebro-spinal 
meningitis  was  observed  by  Dr.  Samuel  Wilks,  in  each  of  the  three 
years  1856,  1858,  1859,  in  the  metropolis.8  In  October,  1859,  a  fatal 
case  of  cerebro-spinal  disorder,  with  petechial  eruption,  came  under 
the  notice  of  Dr.  Henry  Day,  in  the  vicinity  of  Stafford.  In  this  case, 
hyperaBrnia  of  the  meninges  of  the  brain  and  spinal  cord, .and  copious 
effusion  of  fluid  at  the  base  of  the  brain,  were  discovered  after  death. 
A  similar  but  more  rapidly  fatal  case  was  also  observed  by  Dr.  Day, 
in  the  Stafford  General  Infirmary  in  September,  1865.7  The  largest 
and  most  fatal  outbreak  of  epidemic  cerebro-spinal  meningitis  which 
has  occurred  within  the  limits  of  the  United  Kingdom  began  in  Ireland 
in  March,  1866,  and  attained  its  chief  development  in  the  subsequent 
winter.  Its  effects  were  almost  entirely  limited  to  the  sister  island, 
and  the  brunt  of  the  outbreak  fell  upon  Dublin.  Other  localities 
affected  were  Tullamore,  Parsonstown,  Mitchelstown,  Thurles,  Clon- 
dalkin,  and  the  Curragh  camp.  The  cases  were  not  very  numerous  in 
Dublin;  and  in  the  country  towns  they  were  comparatively  few. 
It  is  noteworthy  that,  as  in  the  earlier  outbreaks  in  France,  the  mili- 
tary in  Ireland,  in  proportion  to  their  strength,  suffered  prominently 
from  the  disease.  In  some  of  the  country  districts  cases  were  recorded 
among  the  troops  alone,  or  among  persons  in  immediate  connection, 
with  them.8  In  January  and  February  1867,  an  outbreak  of  a  disease 
characterized  by  severe  rigors,  tetanic  convulsions,  intense  neuralgic 
pain  in  the  head  and  upper  part  of  the  trunk,  increased  sensitiveness 
of  the  surface,  obstinate  vomiting,  restlessness,  and,  in  one  instance  at 
least,  by  a  dark  purple  eruption,  but  of  which  not  a  single  case  died, 
took  place  at  B-irdney,  in  Lincolnshire,  a  village  about  ten  miles  east 
of  Lincoln,  on  the  verge  of  a  fen  country,  and  having  a  population  of 
1500,  the  bulk  of  whom  are  engaged  in  agricultural  pursuits.9  Two 
cases  of  epidemic  cerebro-spinal  meningitis  were  recorded  in  London 
in  the  summer  of  1867.  One,  a  case  of  the  fulminant  form  of  the 
malady,  in  which  death  occurred  in  twenty-seven  hours,  took  place  in 

1  Mr.  Henry  Gervis,  Medico-Chirurgical  Society's  Transactions,  vol.  ii. 
*  Dr.  John  Scott,  Medical  Times  and  Gazette,  1865,  vol.  i.  p.  515. 

3  Sodal  Science  Review,  May,  1865,  p.  398. 

4  Dr.  McDowell,  The  London  Journal  of  Medicine,  1851,  vol  iii.  p.  858. 

5  Dr.  Kennedy,  The  Medical  Press  and  Circular,  June  12,  1861,  p.  551. 

6  The  Lancet,  April  15,  1865,  p.  389. 

7  Clinical  Histories  and  Comments,  1866,  pp.  3-7. 

8  Dr.  E.  D.  Mapother,  and  Staff-surgeon  Dr.   Jeffrey  A.  Marston,  The  Lancet,  July  6 
and  July  13, 1867. 

9  G.  M.  Lowe,  M.B.  The  Lancet,  June  26,  18G7,  p.  790  ;  Mr.  Geo.  Newman  Woolley, 
The  Lancet,  Aug.  3,  1867,  p.  130. 


110  EPIDEMIC    CEREBRO-SPINAL    MENINGITIS. 

June,1  the  other,  a  case  of  the  purpuric  form,  in  which  death  occurred 
in  seven  days,  took  place  in  July.2 

The  peculiarity  of  distribution  of  the  disease  in  the  British  Islands, 
its  epidemic  manifestation  being  limited  to  one  portion  of  the  kingdom, 
and  chiefly,  even  in  recurrent  outbreaks,  to  a  small  section  of  the 
population  of  that  portion,  is  not  an  isolated  phenomenon.  Notwith- 
standing the  wide  geographical  prevalence  of  the  malady  as  shown  by 
the  foregoing  details,  it  must  not  be  concluded  that  this  prevalence 
represents  a  general  diffusion  of  the  disease  among  the  different  popu- 
lations during  the  periods  of  its  activity.  The  outbreaks  of  epidemic 
cerebro-spinal  meningitis,  as  a  rule,  are  limited  to  small  sections  of  a 
population,  and  its  distribution  is  by  a  series  of  isolated  outbreaks, 
rather  than  by  extensive  spreading.  This  was  shown  remarkably,  as 
already  described,  during  the  outbreak  in  France  in  1837  and  follow- 
ing years,  when  the  ravages  of  the  malady  were  principally  confined 
to  certain  garrisons,  and  even  to  small  sections  of  a  garrison,  without 
affecting  the  surrounding  population.  A  like  limitation  of  the  disease 
to  certain  detachments  of  troops  was  observed  during  the  recent  war 
in  the  United  States ;  and  the  restriction  of  the  malady  to  small  por- 
tions of  workhouse  populations,  as  in  the  first  outbreak  in  Ireland,  is 
an  analogous  phenomenon.  Perhaps  the  sole  outbreak  in  which 
an  extensive  diffusion  of  the  disease  among  a  community  'has  oc- 
curred was  that  in  the  province  of  Dantzic,  in  1864-(55.  The  ten- 
dency to  reproduction  in  a  locality,  as  in  Dublin,  was  particularly 
observed  during  the  great  outbreak  in  France  from  1838  to  1848, 
when  the  disease  reappeared  again  and  again  among  the  forces  in 
Bayonne,  Versailles,  and  Avignon,  notwithstanding  changes  of  gar- 
rison. The  freedom  of  England  and  Scotland  from  outbreaks  of  so 
widely  spread  a  malady  is  very  remarkable;  particularly  if  the  seem- 
ing; occasional  cases  of  the  disease  to  which  reference  has  been  made 
are  to  be  regarded  as  true  examples. 

ETIOLOGY.— (a)  Predisposing  Causes. — Age.  The  personal  liability 
to  the  disease  is  not  governed  in  any  definite  manner  by  age.  In  some 
epidemics  children,  in  others  young  people,  in  others  again  adults  of 
from  thirty  to  fifty  years,  have  suffered  in  greatest  proportion. — Sex. 
Generally,  and  in  some  outbreaks  very  markedly,  males  are  more  liable 
to  the  disease  ih&n  females. — Profession.  During  the  outbreaks  of  the 
disease  in  France  from  1837  to  1849,  a  peculiar  proclivity  to  the 
disease  was  observed  among  soldiers.  But  in  subsequent  outbreaks 
in  France,  and  wider-spread  outbreaks  elsewhere,  no  special  liability 
to  the  disease  was  manifested  among  any  vocation. —  Climate  and 
Seasons.  In  the  Eastern  hemisphere  our  knowledge  of  the  disease  is 
limited  to  Western  and  Central  Europe  and  Algeria,  the  northern 
boundary  of  the  district  not  passing  beyond  lat.  61°  N.,  the  southern 
not  beyond  lat.  35°  N. — the  one  extreme  closely  approaching  the  arctic, 
the  other  the  torrid  zone.  In  the  Western  hemisphere  the  records  of 
the  malady  are  confined  to  the  populous  districts  of  the  eastern 

1  Dr.  Edwards  Crisp,  The  Lancet,  June  22,  1867,  p.  773. 

2  Dr.  Thomas  Clark,  The  Lancet,  July  13,  1867. 


ETIOLOGY.  Ill 

division  of  the  United  States,  from  lat.  30°  N.  to  lat.  48°  N.  It  is 
noteworthy  that  the  northern  aud  southern  limits  of  distribution  in 
both  hemispheres  but  slightly  overlap  the  isothermal  lines  5°  and  20°. 
Season  acts  as  an  unquestionable  and  powerful  predisposing  cause  of 
epidemic  cerebro-spinal  meningitis,  which  is  especially  a  disease  of  the 
cold  months.  Of  216  local  outbreaks  in  France  and  the  United  States, 
166  prevailed  between  December  1st  and  May  31st;  50  in  the  other 
six  months  of  the  year.  In  Sweden  of  417  local  outbreaks,  311  took 
place  in  the  former  period  of  the  year,  106  in  the  latter  (STILLE). 
During  the  recent  outbreak  in  Ireland,  the  brunt  of  the  disease  fell 
between  January  and  July,  1867.  Of  85  outbreaks  in  various  parts  of 
Europe  and  the  United  States,  dated  by  Hirsch,  33  prevailed  in  winter, 
24  in  winter  and  spring,  11  in  spring,  1  in  spring  and  summer,  2  in 
summer,  1  in  summer  and  autumn,  1  in  autumn,  1  in  autumn  and 
winter,  3  in  autumn,  winter,  and  spring,  and  6  prevailed  throughout 
the  whole  yean. — Locality  and  soil  do  not  exercise  any  manifest  influ- 
ence over  the  disease.  It  has  been  observed  on  low  grounds,  high- 
lands, and  on  soils  of  the  most  various  character  indifferently. — Sani- 
tary conditions.  No  definite  relation  exists  between  the  sanitary  state 
of  habitations  and  of  individuals  and  the  occurrence  of  the  disease. 
It  has  prevailed  in  some  epidemics  as  well  among  the  affluent  as  the 
impoverished — among  those  who  are  well-fed,  well  housed,  and  well- 
clothed,  as  among  those  who  are  ill-fed,  ill-housed,  and  insufficiently 
clothed.  In  certain  outbreaks,  as  in  that  on  the  Lower  Vistula,  the 
prosperous  classes  suffered  to  a  much  less  extent  from  the  malady  than 
the  poor  and  miserable  who  were  subjected  to  privation  and  much 
foulness  of  persons,  dwellings,  and  atmosphere. 

(b}  Exciting  Causes. — Fatigue  has  been  mentioned  as  an  exciting 
cause.  In  some  of  the  early  outbreaks  of  the  disease  among  French 
troops,  France  being  at  war  at  the  time,  fatigue  apparently  .exercised 
a  determining  influence.  Again,  during  the  recent  outbreak  in 
Ireland,  the  malady  appeared  verv  early  among  a  "  flying  column"  of 
troops  occupied  in  the  suppression  of  the  Fenian  disturbance,  and 
exposed  to  great  fatigue  and  inclemency  of  weather.  But  fatigue 
has  played  little  or  no  part  in  determining  the  disease  among  the 
civil  population,  especially  among  children  and  the  inmates  of  work- 
houses and  prisons. —  Gold.  The  marked  predominance  of  the  disease 
in  the  winter  and  spring  months  has  suggested  a  causal  connection 
with  cold.  Hirsch  has  submitted  the  question  to  a  detailed  examina- 
tion, and  with  this  result:  that,  .although  the  suspicion  cannot  be 
excluded  that  the  temperature  of  winter  and  spring  may  have  some 
direct  effect  upon  the  genesis  of  the  disease,  "the  modifications  in  the 
mode  of  living  incidental  to  these  seasons  exert,  in  a  far  higher  degree 
an  influence  favourable 'to  the  presence  of  this  as  of  many  other  infec- 
tious maladies."1 — Certain  Insanitary  States.  There  is  not  any  con- 
stant or  even  common  relationship  between  any  insanitary  state  and 
the  appearance  of  the  disease.  Neither  foulness  of  house  and  its 
surroundings,  nor  of  the  atmosphere,  whether  from  putrid  emanations 
or  from  overcrowding,  nor  impurity  of  any  other  kind,  has  any  deter- 

1  Transactions  of  the  Epidemiological  Society,  vol.  ii.  p.  369. 


112  EPIDEMIC    CEREBRO-SPINAL    MENINGITIS. 

minate  relation  with  epidemic  cerebro-spinal  meningitis.  But  Hirsch 
remarks1  of  the  outbreak  in  the  province  of  Dantzic  in  1865,  that 
"the  disease  prevailed  exactly  in  that  season  of  the  year  in  which,  oa 
account  of  inclement  weather,  many  individuals  were  crowded  together 
into  small  and  dirty  rooms  kept  constantly  closed  by  their  occupants, 
and  from  which  all  ventilation  was  excluded,  and  in  which  the  before- 
mentioned  unfavourable  hygienic  conditions  [dampness,  great  filth, 
and  an  atmosphere  loaded  with  putrid  emanations]  were  extremely 
perceptible."  -The  causes  here  suggested  have  been  held  to  be  not 
altogether  inoperative  in  other  and  more  circumscribed  outbreaks. — 
Communication  of  the  sick  with  the  well.  The  great  majority  of  observers 
have  come  to  the  conclusion  that  the  disease  is  incommunicable  from 
the  sick  to  the  well.  Among  the  minority  who  hesitate  to  accept  this 
deduction  without  reservation  are  Professor  Hirsch,  Professor  Stokes, 
and  Mr.  J.  Simon.  The  facts  which  suggest  the  possibility  of  the 
active  cause  of  the  disease  being  portable  in  some  way  are  of  the  fol- 
lowing character:  (a)  A  child  was  seized  with  epidemic  cerebro- 
spinal  meningitis,  and  died.  A  second  child  of  the  same  family  was 
attacked  with  the  malady  a  few  days  later.  The  day  following  the 
attack  of  this  child,  the  mother,  who  slept  in  the  same  bed  with  it, 
sickened  of  the  disease.2  (b)  1.  On  the  8th  February,  1865,  a  youth, 
aged  20  years,  was  attacked  with  the  characteristic  symptoms  of 
epidemic  cerebro-spinal  meningitis.  He  was  nursed  by  a  woman  from 
another  village.  The  youth  died,  and  after  his  death  the  woman 
returned  home.  She  soon  sickened,  and  she  died  of  the  epidemic 
disease  on  the  26th  February.  There  had  been  but  one  case  previously 
in  the  village.  To  the  interment  of  the  woman,  the-funeral  obsequies, 
as  customary 'in  the  district,  being  performed  with  the  coffin  open, 
came  a  family  from  another  locality.  After  the  return  home  of  this 
family,  a  child,  three  months  old,  sickened  immediately  of  meningitis 
and  died  within  twenty-four  hours.  Then  a  man  who  had  accompa- 
nied the  family  to  the  interment  was  attacked  with  the  disease,  and 
died  on  the  2d  of  March.  Lastly  a  girl,  in  the  same  locality,  who 
had  also  been  at  the  funeral,  was  seized,  and  died  on  the  7th  March. 
2.  At  another  village,  two  children  of  one  family,  aged  three  and  a  half 
and  one  and  a  half  years  respectively,  died  of  the  epidemic,  one  on  the 
27th  January,  the  other  on  the  7th  February.  The  clothes  of  the 
deceased  were  taken  to  a  neighbouring  village,  and  came  into  the  pos- 
session of  a  girl  aged  five  years.  She  soon  sickened  of  the  epidemic, 
and  died  on  the  14th  February.3  (c)  Boudin  relates  instances  of  the 
appearance  of  the  disease  in  garrisons,  and  among  the  civil  popu- 
lation of  towns,  after  the  introduction  of  detachments  of  troops  among 
whom  the  disease  had  prevailed  or  was  prevailing  at  the  time. 

The  foregoing  facts  simply  suggest  the  possibility  of  the  active  cause 
of  epidemic  cerebro  spinal  meningitis  being  communicable  by  the  sick 
to  the  well.  This  possibility,  notwithstanding  the  apparent  formida- 
ble array  of  facts  to  the  contrary,  is  not  to  be  lightly  dealt  with.  The 

i  Transactions  of  the  Epidemiological  Society,  vol.  ii.  p.  372. 

*  Professor  Stokes,  The  Medical  Press  and  Circular,  June  19,  1867,  p.  581. 

8  Hirsch,  Transactions  of  Epideuiiological  Society,  vol.  ii.  p.  373. 


ETIOLOGY.  113 

lesson  taught  by  the  difficulties  and  doubts  which  beset  the  discovery 
of  the  communicability  of  typhoid  fever  and  of  cholera  will  have  been 
strangely  misunderstood  if  it  is  necessary  to  urge  upon  observers  the 
importance  of  keeping  the  question  of  the  possible  communicability 
of  epidemic  cerebro-spinal  meningitis  constantly  before  the  mind.  In 
the  consideration  of  this  question,  however,  a  caution  is  needed.  The 
term  "contagion"  is  used  too  indiscriminately.  It  has  been  so  long 
employed  to  express  the  manner  of  transmission  of  disease  which  is 
witnessed  in  smallpox,  scarlet  fever,  or  typhus,  that  it  is  difficult  to 
dissociate  the  idea  of  this  manner  from  the  word.  It  is  almost  impos- 
sible in  reading  the  opinions  of  those  writers  who  have  come  to  the 
conclusion  that  epidemic  cerebro-spinal  meningitis  is  not  a  "contagious" 
disease,  to  avoid  the  suspicion,  from  their  use  of  the  adjective,  that 
they  have  looked  upon  the  question  too  exclusively  from  the  point  of 
view  suggested  by  the  diseases  named.  It  is  obvious  that  contagious- 
ness of  a  like  character  to  that  of  smallpox,  scarlet  fever,  or  typhus, 
is  not  possessed  by  the  malady  under  consideration.  The  question 
is:  Does  epidemic  meningitis,  like  typhoid  fever  or  cholera,  possess  a 
peculiar  contagiousness  of  its  own,  a  property  of  communicability 
peculiar  to  itself?  This  has  yet  to  be  solved.  Another  explanation 
of  the  facts  which  appear  to  indicate  a  possible  communicability  of 
the  disease  from  the  sick  to  the  well  is,  however,  open,  and  is  set 
forth  in  the  next  paragraph. 

Diseased  grain. — Dr.  B.  W.  Eichardson  has  suggested  that  epidemic 
cerebro-spinal  meningitis  may  possibly  arise  from  the  consumption  of 
diseased  grain,  after  the  manner  of  ergotism,  and  perhaps  acrodynia. 
He  thinks  that  the  probabilities  are  altogether  in  favour  of  the  sug- 
gestion, that  "  the  cause,  in  fact,  is  a  diseased  grain,  or  fungus,  con- 
tained in  some  kinds  of  flour  out  of  which  the  bread-stuffs  are  made. 
This  fungus  may  not  be  present  in  large  quantities,  and  many  persons 
may  eat  of  the  food  without  getting  a  poisonous  part;  but  one  will 
get  it  out  of  a  number,  and  this  without  any  communication  beyond 
the  breaking  of  bread  together :  the  disease  may  occur  in  one  member 
of  a  family,  leaving  the  rest  free,  and  in  this  irregular  way  it  may  be 
distributed,  in  an  epidemic  form,  over  a  large  surface  of  the  country." 
He  adds,  "  If  my  hypothesis,  as  regards  cause,  be  correct,  there  is  little 
danger  of  the  disorder  extending  widely  in  this  country;  for  of  our 
cereals  used  as  food,  nearly  the  whole  of  the  population  now  select 
wheat,  and  our  wheat  generally  is  selected  for  the  market  with  great 
judgment  and  circumspection.  Any  cases,  therefore,  that  might  occur 
would  be  isolated,  and  would  be  easily  traced  out  and  prevented."1 
This  suggestion  opens  out  an  altogether  new  field  of  inquiry  respect- 
ing the  origin  of  the  disease,  and  it  demands  active  and  thoughtful 
consideration  in  subsequent  outbreaks.  Dr.  H.  Day,  of  Stafford,  has 
endeavoured,  by  experiments  on  the  lower  animals,  to  obtain  some 
light  on  the  subject.  He  fed  three  rabbits  with  unsound  grain  (wheat, 
oats,  ergot  of  rye,  and  mouldy  bread)  with  this  result :  In  all  the  animals 
a  spasmodic  affection  was  produced,  and  in  two  inflammatory  changes 

1  Social  Science  Review,  May,  1865,  p.  403. 
8 


114  EPIDEMIC    CEREBRO-SPINAL    MENINGITIS. 

in  the  right  eye,  proceeding  in  one  case  to  ulceration  of  the  cornea, 
and  evacuation  of  the  contents  of  the  globe.  One  of  the  rabbits  died 
on  the  eighth  day,  the  other  two  were  killed  on  the  twelfth  day,  and 
in  all  more  or  less  congestion  of  the  membranes  of  the  spinal  cord  was 
found  on  dissection.1 

The  sum  of  our  knowledge  of  the  etiology  of  epidemic  cerebro- 
spinal  meningitis  is  this;  that  the  clue  to  its  explanation  has  not  been 
discovered. 

NATURE. — 1.  Is  the  disease  malarious,  as  suggested  by  some  writers? 
The  outbreaks  in  which  the  disease  has  occurred  in  malarious  districts, 
or  in  which  the  malady  has  shown  an  intermittent  character,  are  too 
few  in  number  to  admit  of  much,  if  any,  doubt  resting  upon  the  answer. 
There  is  no  sufficient  ground  for  believing  that  the  malady  is  of  mala- 
rious origin.  The  numerous  examples  of  prevalence  of  the  disease  in 
localities  free  from  malaria  set  the  question  aside  definitely.  Even 
when  intermissions  or  remissions  have  been  observed  in  the  progress 
of  the  malady,  it  must  not  be  hastily  assumed  that  they  are  consequent 
upon  malarious  poisoning.  Hirsch  has  shown  that  certain  cases  of 
epidemic  cerebro-spinal  meningitis,  distinguished  by  intermissions  and 
remissions,  which  came  under  his  observation,  took  place  in  the  course 
of  an  outbreak  in  a  district  free  from  malaria.  Further,  he  states  that 
this  outbreak  prevailed  at  a  season  (winter)  and  in  a  state  of  climate 
(intense  cold)  which  notoriously  exclude  the  prevalence  of  malarious 
diseases,  even  where  endemic;  that  the  period  of  life  (1 — 5  years) 
least  liable  to  malarious  disease  furnished  the  largest  contingent  of 
victims,  while  the  classes  most  advanced  in  life,  and  who  are  most 
liable,  escaped  the  epidemic  in  a  remarkable  degree.  Finally,  the 
infallible  test  of  malarious  disease,  quinine,  by  its  in  utility  in  cases 
of  the  epidemic  which  assumed  an  intermittent  or  remittent  character, 
showed  the  non-malarious  nature  of  the  affection.*  2.  Is  epidemic 
cerebro-spinal  meningitis  a  form  of^  or  allied  to,  typhus?  Epidemic 
cerebro-spinal  meningitis  differs  from  typhus  in  the  aspect  of  the 
patient,  rhythmical  progress,  range  and  course  of  temperature,  form 
of  cerebral  affection,  character  of  eruption,  sequelae,  rate  of  mor- 
tality, anatomical  lesions,  and  manner  of  dissemination.  Differing  in 
all  essential  particulars,  doubt  can  only  arise  when  the  two  diseases 
prevail  together.  Under  such  circumstances,  cases  of  the  fulminant 
and  purpuric  forms  of  the  one  malady  may  be  difficult  to  discriminate 
from  the  graver  and  more  rapidly  fatal  forms  of  the  other.  Doubt 
also  may  arise  when  in  the  course  of  the  former  disease  typhous  or 
tvphoid  symptoms  occur.'  But  such  a  doubt  applies  equally  to  the 
discrimination  of  the  disease  from  measles  and  typhoid  fever,  as  from 
typhus.  3.  Is  epidemic  cerebro-spinal  meningitis  a  true  or  a  pseudo- 
epidemic  disease?  Is  this  disease  a  true  epidemic  disease  in  the  sense 
of  its  being  due  to  a  specific,  febrile  poison  (to  which  class  of  diseases 
the  term  epidemic  is  now  well-nigh  alone  restricted)?  Or  is  it  a 
pseudo-epidemic  malady,  as  being  an  exaggerated  and  more  prevalent 

1  Clinical  Histories  and  Comments,  pp.  18-23. 

*  Transactions  of  the  Epideuiiological  Society,  vol.  ii.  p.  377. 


NATURE.  115 

form,  from  certain  climatic  conditions,  of  an  idiopathic  inflammatory 
affection  of  the  brain  and  spinal  cord  ?  No  absolute  distinction  can 
be  drawn  between  sporadic  cerebro-spinal  meningitis  and  the  epidemic 
malady  of  the  same  name.  But  there  are  certain  broad  and  well- 
defined  differences.  The  conjoined  inflammatory  affection  of  the 
covering  membranes  of  the  brain  and  spinal  cord,  which  is  the  rule  in 
epidemic  cerebro-spinal  meningitis,  is  a  rare  exception  in  sporadic 
inflammation  of  the  envelopes  of  the  central  nervous  centres.  Again, 
the  indications  of  blood-change  which  are  so  common  in  the  epidemic 
disease  are  never,  or  only  in  most  exceptional  cases,  witnessed  in  the 
sporadic  disease.  It  has  been  suggested  that  the  blood-change  and 
herpetic  and  purpuric  eruptions  may  be  of  nervous  origin,  and  con- 
sequent upon  the  profound  alteration  in  the  nervous  system.  It  has 
been  suggested,  also,  that  the  purpuric  eruption  of  epidemic  cerebro- 
spinal  meningitis  may  be  one  of  several  signs  of  a  general  tendency 
to  purpura  in  disease,  and  merely  an  incidental  phenomenon  of  the 
epidemic  malady.  Thus,  in  Dublin  (1866-67),  purpura  had  been  ob- 
served in  rheumatic  fever,1  and  there  was  an  outbreak  of  purpura 
among  swine,2  contemporaneously  with  the  epidemic.  The  first  sug- 
gestion touches  a  very  curious  question,  which  as  yet  does  not  admit 
of  solution.  But  it  is  worthy  of  remark  that  the  form  of  eruption 
which  of  all  others  is  peculiar  to  epidemic  cerebro-spinal  meningitis 
is  the  herpetic,  a  form  which,  in  some  of  its  manifestations  at  least,  as 
in  herpes  labialis,  shingles,  has  singular  neurotic  relations.  Mr.  Jona- 
than Hutchinson  has  propounded  the  riddle,  Is  herpes  zoster  an  exanthem 
or  neurosis?*  This  is  certain,  that  it  is  a  symptom  which  has  some 
definite  connection  with  lesion  of  nerve  trunks,  if  not  nerve  centres. 
The  facts  upon  which  the  second  suggestion  is  based  are  of  interest, 
but  they  form  too  narrow  a  basis  for  conclusions.  It  is  noteworthy 
that  rare  cases  of  cerebro-spinal  meningitis  are  observed  in  the  inter- 
vals of  epidemic  prevalence  of  the  disease,  even  in  this  country  (H. 
DAY;  WiLKS4).  These  cases  are  of  much,  although  as  yet  uudeter- 
minate  interest,  in  reference  to  the  etiology  of  the  disease.  4.  Is  epi- 
demic cerebro-spinal  meningitis  a  disease,  sui  generis?  The  association  of 
symptoms  shows  that  it  is  an  independent  malady;  the  aptitude  to 
blood-changes  in  the  course  of  the  disease,  judged  by  analogy  with  like 
changes  which  occur  in  acute  specific  diseases,  suggests  the  inference 
that  it  is  also  dependent  upon  a  specific  poison,  from  whatever  source 
derived.  This  is  the  deduction  which  appears  to  have  the  highest 
degree  of  probability  in  the  present  state  of  our  knowledge. 

An  intercurrent  question  arises  here:  Is  the  fulminant  form  of 
epidemic  cerebro-spinal  meningitis  really  a  variety  of  the  disease,  or 
a  different  malady  altogether?  Dr.  R.  D.  Lyons  maintains  that  in 
the  recent  prevalence  of  the  epidemic  in  Dublin,  two  independent 
diseases  existed.  The  one  characterized  by  its  collapse,  profuse  pur- 
puric eruption,  great  rapidity  of  course,  fatality,  and  absence  of  ana- 
tomical lesion  in  the  nervous  centres  after  death,  he  designates  febris 

1  Dr.  Banks,  The  Medical  Press  and  Circular,  June  19, 1867,  p.  580. 

1  Dr.  Mapother,  The  Lancet,  July  13,  18(37,  p.  39. 

3  London  Hosp.  Reps.,  vol.  iii.  p.  70.  4  The  Lancet,  April  15,  1865,  p.  388. 


116  EPIDEMIC    CEREBRO-SPINAL    MENINGITIS. 

nigra;  the  other  was  the  disease  commonly  known  as  cerebro-spinal 
meningitis.  But  it  is  to  be  remarked  that  the  two  varieties  of  disease 
have  never  been  observed  except  in  the  same  epidemic;  that  they 
pass  by  insensible  grades  the  one  into  the  other  ;  that  the  most  highly 
developed  symptoms  of  the  so-called  febris  nigra  sometimes  occur 
together  with  the  most  marked  symptoms  of  cerebro-spinal  meningitis ; 
and  that  it  is  more  consistent  with  experience  to  consider  the  two 
series  of  symptoms  as  indications  of  one  and  the  same  malady,  rather 
than  two  maladies  going  forward  at  the  same  time  in  the  same  patient. 
A  second  iutercurrent  question  is,  whether  the  purpuric  form  of  the 
disease  be  of  scorbutic  origin  ?  The  question  amounts  to  little  more 
than  a  suggestion.  There  are  no  facts  which  support  an  affirmative 
answer;  for,  apart  from  other  well  known  signs,  purpuric  spots  are 
not  indications  of  a  scorbutic  taint. 

TREATMENT. — Prophylactic. — Ignorance  of  the  true  etiology  of  the 
disease  limits  our  preventive  efforts  to  general  sanitary  measures, 
applicable  to  all  epidemic  diseases,  for  the  purification  of  houses  and 
localities.  Mr.  J.  Simon,  recording  the  conditions  under  which  the 
disease  has  prevailed,  writes :  "  I  am  strongly  of  opinion  that  the  best 
sanitary  precaution  which  in  the  present  state  of  knowledge  can  be 
taken  against  the  disease,  must  consist  in  care  for  the  ventilation  of 
dwellings."  He  adds,  however,  "  that  in  some  cases,  according  to  local 
reports,  the  distribution  of  an  epidemic  has  very  decidedly  not  been 
governed  by  conditions  of  overcrowding  and  ill- ventilation."  Dr.  B.  W. 
Richardson's  suggestion  as  to  the  cause  of  the  disease  should  lead  to 
the  careful  microscopic  examination  of  all  bread  stuffs  and  farina- 
ceous preparations  in  use  among  families  and  communities  where  the 
disease  breaks  out,  and  the  disuse  of  such  as  may  be  of  doubtful  cha- 
racter. 

Curative. — The  treatment  of  epidemic  cerebro-spinal  meningitis  is 
as  unsatisfactory  as  that  of  cholera.  The  evidence  of  the  course  of  the 
disease  having  been  beneficially  affected  in  any  outbreak  by  the  ad- 
ministration of  medicine  is  very  doubtful.  The  too  common  rapid 
progress  of  the  malady  to  death,  as  in  cholera,  and  the  nature  of  the 
lesions  determining  death,  necessarily  set  at  naught  efforts  to  control 
it;  medicine  not  being  guilty  either  of  inaptitude  or  inactivity.  The 
control  of  this  disease,  as  of  cholera  or  trichiniasis,  is  a  question  of 
preventive  rather  than  curative  treatment,  and  must  depend  upon  the 
discovery  and  limitation  of  its  cause.  In  the  earlier  outbreaks,  epi- 
demic cerebro-spinal  meningitis  was  treated  as  an  acute  inflamma- 
tory affection,  by  bleeding  and  purgatives,  with  the  general  result 
that  the  fatality  of  the  malady  was  probably  invariably  augmented. 
During  the  recent  outbreak  in  Philadelphia,  it  was  found  that,  in  the 
more  asthenic  cases,  cupping  the  nape  of  the  neck  was  "  of  essential 
service  in  mitigating,  and  generally,  indeed,  in  wholly  removing  the 
neuralgic  pains  which  form  so  prominent  and  so  severe  a  symptom 
in  many  cases  of  the  disease"  (STILLE).  When  the  state  of  the  patient 
forbade  the  abstraction  of  blood,  dry-cupping  used  in  the  same  locality 
afforded  signal  relief,  and  rendered  the  effects  of  vesication  more 


TREATMENT.  117 

prompt  and  complete.  This  was  the  experience  of  one  of  the  least 
fatal  outbreaks  recorded.  The  experience  of  the  majority  of  epi- 
demics has  been  against  any  bloodletting,  local  or  general.  The 
deduction  to  be  derived  as  to  depletion  from  the  general  state  of  the 
circulation  and  the  results  of  practice  entirely  coincide.  For,  as  a 
rule,  the  pulse  from  the  very  outset  contraindicates  the  withdrawal 
of  blood ;  and,  if  in  any  case  it  should  seem  from  the  general  symp- 
toms that  depletion  might  exercise  some  control  over  the  central  mis- 
chief, a  thoughtful  regard  should  be  given  to  the  future.  The  application 
of  cold  to  the  head  and  spine,  either  by  means  of  ice  or  a  freezing  mix- 
ture, in  Bsmarch's  India-rubber  bags,  is  not  open  to  the  same  objection 
as  bloodletting,  and  has  furnished  by  far  the  most  satisfactory  results 
of  all  direct  treatment  of  the  acute  cerebro-spinal  symptoms.  In  its 
use  care  should  be  taken  not  to  prolong  the  application  so  as  to  depress 
or  increase  the  depression  already  existing  of  the  whole  system.  When 
the  acute  nervous  symptoms  are  accompanied  by  marked  prostration, 
it  is  advisable  during  the  application  of  the  ice  to  swathe  the  limbs 
in  hot  flannels,  pack  the  legs  and  thighs  with  hot-water  bottles,  or 
bags  filled  with  hot  sand  or  salt,  and  cover  the  abdomen  with  thick 
layers  of  flannel  or  cotton-wool.  From  the  very  outset  of  the  disease, 
care  should  be  taken  to  economize  the  temperature  of  the  body,  and 
anticipate  its  fall ;  and  in  cases  characterized  by  collapse,  or  much 
vital  depression,  the  application  of  external  heat  in  the  manner  just 
suggested  is  a  cardinal  point  of  treatment.  Of  medicaments  directly 
addressed  to  the  nervous  symptoms,  opium  is  the  most  valuable.  It  is 
especially  indicated  when  there  are  much  restlessness,  acute  delirium, 
sleeplessness,  hyperassthesia,  and  painful  spasm.  Morphia  is  the  best 
form  of  administration,  and  subcutaneous  injection  perhaps  the  best 
mode.  The  drug  should  be  given  in  decided  and  frequently  repeated 
doses,  and  carefully  watched.  Stille'  says  of  its  use  during  the  recent 
outbreak  in  Philadelphia:  "We  were  in  the  habit  of  giving  one  grain 
of  opium  every  hour,  in  very  severe,  and  every  two  hours  in  mode- 
rately severe  cases,  and  in  no  instance  was  produced  either  narcotism, 
or  even  an  approach  to  that  condition.  Under  the  influence  of  the 
medicine  the  pain  and  spasm  subsided,  the  skin  grew  warmer,  and  the 
pulse  fuller,  and  the  entire  condition  of  the  patient  more  hopeful.  It 
seemed  probable,  however,  that  the  full  benefit  of  the  opium  treatment 
could  be  received  by  those  only  who  were  subjected  to  it  in  the  early 
stages  of  the  attack.  Direct  experience  is  here  in  perfect  accord  with 
the  expectation  which  a  knowledge  of  the  pathological  processes  in- 
volved in  the  disease  would  naturally  suggest." 

A  Committee  of  the  American  Medical  Association  has  reported 
favourably  of  the  sulphate  of  quinia  in  large  doses,  given  at  the  very 
beginning  of  the  disease.  In  some  instances  the  drug  seemed  to 
abort  the  attack.  The  committee  speaks  also  of  the  favourable  results 
reported  from  the  combined  use  of  ergot  and  chloride,  of  iron.  Some 
American  physicians  have  given  ergot  in  combination  with  belladonna, 
and  belladonna  in  combination  with  quinine,  but  with  equivocal  benefit. 
Mercurials  have  been  freely  used,  particularly  in  the  form  of  calomel, 
but  their  effect  has  been  most  questionable,  except  as  purgatives. 


118  EPIDEMIC    CEREBRO-SPINAL    MENINGITIS. 

Their  indiscriminate  use  is  to  be  utterly  condemned,  and  their  use  at 
all  to  be  discountenanced.  A  host  of  other  medicaments  have  been 
made  use  of,  of  which  it  is  requisite  to  note  only  iodide  of  potassium, 
bromide  of  potassium,  and  arsenite  of  potash.  The  circumstances  under 
which  the  two  former  drugs  have  been  used,  and  are  most  likely  to 
prove  beneficial,  will  suggest  themselves  to  the  practitioner.  It  does 
not  appear  that  any  decided  good  has  arisen  from  their  administra- 
tion. In  protracted  cases  of  convalescence  the  arsenite  of  potash  may 
prove  a  valuable  remedy. 

Of  the  general  treatment  of  the  patient  the  hot  bath  (102°-103°) 
is,  when  practicable,  the  most  important.  This  should  be  followed, 
as  recommended  by  the  Committee  of  the  American  Medical  Asso- 
ciation, by  friction  with  warm  oil  of  turpentine.  The  regimen  should 
be  generous  and  nutritious  from  the  beginning  of  the  disease.  In 
the  acute  stages  soup  of  some  kind  or  other,  or  milk,  is  needed  ;  and 
as  soon  as  appetite  returns,  solid  viands  of  any  digestible  character 
must  be  given.  In  the  graver  cases  where  there  is  much  restlessness 
and  spasm  or  stupor,  and  food  cannot  be  given  by  the  mouth  from 
the  patient's  refusal  or  inability  to  swallow,  an  attempt  should  be 
made  to  administer  it  by  the  rectum :  when  there  is  much  thirst,  the 
patient's  fierce  desire  for  drinks  may  be  freely  indulged.  The  state 
of  the  pulse  is  the  principal  guide  to  the  use  of  stimulants.  Their 
administration  as  a  special  remedy  independently  of  the  indications 
which  generally  govern  their  use  has  not  been  followed  by  good  results; 
but  they  are  called  for  when  the  condition  of  the  pulse  and  the  aspect 
of  the  patient  show  manifest  flagging  of  the  vital  power.  The  sequelae 
of  the  disease  must  be  treated  on  ordinary  principles. 

Too  frequently  the  state  of  the  patient  as  to  delirium,  spasm,  and 
irritability  of  the  stomach  prevents  all  internal  treatment  whether  by 
medicine  or  food,  and  limits  the  efforts  of  the  physician  to  external 
measures,  restricting  even  their  application.  To  this  unhappy  com- 
bination of  unfortunate  and  uncontrollable  conditions  may  reasonably 
be  attributed  to  some  extent  the  inefficacy  of  treatment. 

BIBLIOGRAPHY. — In  addition  to  the  references  in  the  text  may  be 
noted :  The  Eighth  Report  of  the  Medical  Officer  of  the  Privy  Coun- 
cil, containing  Mr.  J.  Simon's  Memorandum  on  the  Disease,  and  Dr. 
J.  Burdon  Sanderson's  Report  on  the  Epidemics  prevailing  about  the 
Lower  Vistula  in  the  beginning  of  1865. — Discussion  in  the  Medical 
Society  of  the  College  of  Physicians  of  Ireland ;  The  Medical  Press 
and  Circular  for  May  29th,  June  5th,  12th,  and  19th,  1867.— Transac- 
tions of  theAmerican  Medical  Association,  vol.  xvii.,  1866,  containing 
a  Report  of  a  Committee  on  the  Disease. — Dr.  W.  H.  H.  Githen's 
Notes  of  98  cases;  The  American  Journal  of  the  Medical  Sciences, 
July,  1867. — Dr.  S.  Gordon;  Dublin  Quarterly  Journal  of  Medicine, 
May,  1867.— Dr.  C.  Murchison;  The  Lancet,  1865,  vol.  i.  p.  41.— Prof. 
A.  Hirsch,  Handbuch  der  historisch-geographischen  Pathologic,  1866, 
vol.  i.  p.  1(53;  Die  Meningitis  Cerebro-spinalis  Epidemica  vom  histo- 
risch-geographischen und  pathologisch-therapeutischen  Standpunkte, 
1866. — Dr.  Stille",  Epidemic  Meningitis  or  Cerebro-spinal  Meningitis, 


BIBLIOGRAPHY.  119 

8vo.,  1867,  Philadelphia.  This  work  contains  a  very  copious  biblio- 
graphy, particularly  valuable  for  its  references  to  American  mono- 
graphs.— Gr.  Tourdes,  Histoire  de  1'Epidemie  de  Meningite  Cerebro- 
Spinale  observed  a  Strasbourg  en  1840  et  1841.  Paris,  1842.— J.  Ch. 
M.  Boudin,  Traite  de  Geographic  et  de  Statistique  Medicales  et  des 
Maladies  End^miques,  vol.  ii.  p.  564 ;  Paris,  1857. — Consult  Hirsch's 
great  work  and  monograph. 


120  DISEASES    OF    THE    NERVES. 


III. 

NEURITIS  AND  NEUROMA. 

By  J.  WARBURTON  BEGBIE,  M.D.,  F.R.C.P.E. 

MORBID  appearances,  the  results  of  inflammatory  action,  are  occasion- 
ally met  with'in  nerves.  Such,  are  the  consequences  usually  of  injury ; 
the  nerves  have  been  divided  by  a  sharp  instrument ;  or,  if  independent 
of  wounds,  they  are  in  all  probability  connected  with  rheumatism  or 
gout.  There  seems  no  reason  to  doubt  that  inflammatory  action  may 
likewise  extend  to  nerves  from  the  contiguous  tissues. 

In  its  general  characters  Neuritis  resembles  the  inflammation  of 
fibrous  tissue.  The  fibrous  investing  sheath  of  nerves,  or  neurilernma, 
is  indeed  its  usual  seat;  the  appearances  of  inflammatory  action  being 
for  the  most  part  limited  to  it,  and  only  seen  in  the  form  of  red  soft- 
ening of  the  nervous  tissue  itself  when  the  inflammation  has  been  of 
an  intense  description. 

A  doubt  as  to  the  spontaneous  occurrence  of  Neuritis  has  been 
entertained  and  expressed  by  several  authorities.  Boerhaave,  for 
example,  writes :  "  Nemo  forte  unquam  vidit  inflammationem  in  nervo  ; 
haec  vero  si  contingat,  in  sola  tunica  vaginali  haBret."1  Others,  again, 
with  even  greater  inaccuracy,  have  maintained  the  frequent  existence 
of  Neuritis.*  Pathologically  the  inflammation  of  nerves  may  be  acute 
or  chronic ;  and  these  two  conditions  are  described  by  Rokitansky  as 
follows :  The  marks  of  the  former  (acute)  are — (a)  Injection  and 
redness.  The  injection  presents  a  linear  arrangement,  and  the  redness 
is  partly  caused  by  injection,  and  partly  by  small  extravasations.  (6) 
Looseness,  succulence,  and  swelling  of  the  nervous  cord,  due  to  infil- 
tration of  serum  into  the  tissue  of  the  neurilemrna,  and  into  the  sheaths 
between  the  primitive  nervous  filaments.  The  nerve  has  lost  its 
smooth,  white,  glistening  appearance;  its  neurilemma  is  opaque,  and 
has  a  rough  and  wrinkled  look,  (c)  Exudation.  This  is  generally  a 
grayish  or  yellowish-red  gelatinous  product,  which  sooner  or  later 
becomes  firm.  It  occupies  the  sheath  and  tissue  of  the  neurilemma, 
and  is  likewise  effused  between  the  primitive  filaments  themselves. 
(d)  The  cellular  tissue  around  the  nervous  cord  always  participates  in 
these  changes;  it  becomes  injected,  reddened,  and  infiltrated  with  a 
serous  or  sero  fibrinous  fluid.  Not  only  the  neighbouring  cellular  tis- 

1  De  Morbis  Nervorum. 

2  See  on  this    point    Animadversiones  de  Nenritide.      Praxeos    Medicae  Universae 
Prsecepta,  auctore  Josepho  Frank  ;  Partis  secundae  volumen  primura,  Sectio  secnnda. 
p.  131  :  also  Elements  of  General  and  Pathological  Anatomy,  by  David  Craigie,  M.  D., 
p.  379. 


NEURITIS    AND   NEUROMA.  121 

sue,  but  the  sheaths  of  the  muscles,  the  fascia,  the  subcutaneous  cellular 
tissue,  and  the  general  integuments,  become  involved. 

Such  a  degree  of  inflammation  as  that  now  described  may  terminate 
in  resolution,  occurring  quickly  or  slowly  in  different  cases,  or  in  indu- 
ration of  the  nerve,  and  a  permanent  loss  of  its  function  in  whole  or 
in  part.  If  the  latter  be  the  result,  the  nerve  continues  thickened, 
and  more  or  less  misshapen,  forming  a  grayish  cord,  which  is  some- 
times marked  with  black  pigment  and  crossed  by  varicose  vessels. 
The  nerve  filaments  diminish  in  size  and  finally  disappear,  this  result 
being  in  part  due  to  the  pressure  to  which  they  are  exposed  by  the 
inflammatory  product,  and  in  part  to  their  interrupted  nutrition,  for 
the  vessels  are  obliterated  by  the  inflammatory  process,  (e)  In  a  more 
intense  inflammation  the  primitive  nervous  filaments  are  destroyed. 
They  are  found  in  a  state  of  red  or  grayish  or  yellowish-red  softening, 
while  the  neurilemma  is  easily  torn.  (/)  The  fluid  product  of  the 
inflammation  may  be  purulent;  and  if  so,  the  nerve  appears  highly 
discoloured,  and  infiltrated  with  purulent  fluid  tinged  with  blood.  The 
neurilemma  is  then  much  altered,  and  readily  gives  way,  while  the 
nerve  is  converted  into  a  yellowish  red,  brownish-red,  or  chocolate- 
coloured  pulp.  The  cellular  tissue  surrounding  the  nerve  becomes 
infiltrated  with  yellow  fibrinous  exudation,  and  abscesses  are  formed 
in  its  course,  (g)  Ulcerative  destruction  of  the  nerve  is  the  next  step. 
But  if  the  progress  of  inflammation  be  stayed  before  that  point  is 
reached,  granulations  appear,  which  become  progressively  changed 
into  cicatrix  tissue,  as  is  observed  in  the  stump  of  a  nerve  after  ampu- 
tation. Nerves,  however,  resist  for  a  lengthened  period  the  suppura- 
tive  and  sanious  destruction  which  may  be  going  on  around  them. 

Chronic  Inflammation  is  characterized  by  the  varicose  state  of  the 
vessels  of  the  affected  nerve,  by  products  which  become  indurated,  and 
gradually  increase  in  quantity,  and  by  a  change  of  the  nerve  to  a 
slate  or  lead-gray  colour.  Sometimes  the  products  are  not  deposited 
uniformly  throughout  the  nerve,  and  then  nodular  swellings  are  formed 
on  it.1  Romberg,  when  directing  attention  to  the  anatomical  know- 
ledge we  possess  of  sciatica,  speaks  of  Neuritis  being  found,  but  of  its 
rare  occurrence.3  The  same  writer,  however,  refers  to  the  possible 
production  of  Neuritis,  by  the  sciatic  plexus  being  dragged  and  irri- 
tated by  the  head  of  the  child  in  a  difficult  labour.  Valleix  and  Beau 
have  described  inflammation  of  nerves  more  systematically  than  other 
authors.  The  latter  has  at  considerable  length,  in  his  interesting 
memoir  on  the  subject,  directed  attention  to  "  Intercostal  Neuritis."3 
Reference  has  been  made  to  the  occurrence  of  a  rheumatic  or  gouty 
Neuritis.  Dr.  Gr.  B.  Wood  considers  it  to  be  highly  probable  that  in 
a  large  proportion  of  cases  rheumatism  lies  at  the  foundation  of  the 
disease.4  And  Dr.  Garrod,  while  admitting,  according  to  the  usually 

received  notion,  that  the  nervous  affections  occurring  in  connection 

• 

1  A  Manual  of  Pathological  Anatomy,  by  Carl  Rokitansky.     Sydenham  Society's 
Translation,  vol.  iii.  p  4(52. 

2  Lehrbuch  der  Nervenkrankheiten  des  Menschen.     Neuralgie  des  Huftnerven. 

8  Valleix,  Guide  du  Medecin  Praticien,  t.  iv.  p.  299;   also  Trait6  des   Nevralgies. 
Beau,  Archives  G6n<5rales  de  Mcdecine,  4e  serie,  t.  xiii.     1847. 
4  A  Treatise  ou  the  Practice  of  Medicine,  vol.  ii.  p.  843. 


122  DISEASES    OF    THE    NERVES. 

with  gout  are  generally  functional,  believes  them  sometimes  to  be 
dependent  on  inflammatory  action,  which,  he  adds,  appears,  so  far  as 
can  be  ascertained,  to  have  the  character  of  true  gouty  inflammation.1 

The  most  characteristic  symptom  of  Neuritis  is  pain,  not  limited  to 
the  precise  seat  of  the  inflammation,  but  felt  in  the  course  of  the  nerve, 
and  sometimes  to  its  minutest  branches.  Besides  its  severity,  the 
pain  in  Neuritis  possesses  other  distinctive  features;  it  is  darting,  and 
tingling,  and  there  often  accompanies  it  a  feeling  of  numbness.  The 
pain  has  been  further  described  as  intermittent,  but  is  more  probably 
remittent,  being,  as  Jong  as  the  disease  continues,  never  entirely  ab- 
sent. Tenderness  over  the  affected  nerve  invariably  exists.  It  is 
possible  that  in  some  forms  of  local  palsies  (see  Local  Paralysis  from 
Nerve  Disease)  the  loss  of  power,  partial  or  complete,  as  weK  as  the 
existence  of  various  morbid  sensations,  of  which  formication  is  one, 
and  perhaps  the  most  common,  is  due  to  disorganization  or  other 
permanent  change  in  the  trunk  of  a  nerve,  resulting  from  inflamma- 
tory action. 

It  seems  to  be  generally  admitted  that  the  nerve  most  liable  to  such 
change  is  the  sciatic:  but  the  various  branches  of  the  brachial  plexus, 
and  especially  the  ulnar  nerves,  likewise  suffer;  and  so  in  all  proba- 
bility do  at  times  the  other  nerves  in  both  lower  extremities  and 
trunk. 

That  inflammation  may  also  attack  the  nerves  of  special  sense,  as 
Dr.  Wood  has  conjectured,  seems  not  improbable,  particularly  the 
nerves  of  hearing  and  of  sight.  Most  assuredly  a  true  goaty  inflamma- 
tion, apparently  commencing,  in  some  cases,  in  the  nerves  themselves, 
not  unfrequently  either  damages  or  entirely  destroys  one  or  other  of 
the  delicate  organs  connected  with  these  most  important  functions. 

In  the  treatment  of  Neuritis  the  probable  alliance  of  the  affection 
with  some  peculiar  diathetic  condition,  the  gouty  or  rheumatic,  or 
possibly  with  the  syphilitic  cachexia,  must  not  be  lost  sight  of. 

Local  abstraction  of  blood,  and  the  application  of  emollient  and 
anodyne  poultices,  rest,  low  diet,  and  the  use  of  laxatives,  are  the 
chief  remedies  in  cases  of  the  acute  Neuritis.  When  the  disease  is 
chronic,  the  use  of  blisters,  issues,  and  even  the  cautery,  have  been 
recommended.  Internally,  besides  opium  or  other  narcotic  for  the 
relief  of  pain,  it  will  be  prudent  to  give  a  fair  trial  in  both  the  acute 
and  chronic  Neuritis  to  quinine,  and  colchicum,  the  iodide  and  the 
bromide  of  potassium. 

NEUROMA  (Tumour  of  Nerve). — Growths  of  various  sizes  and  natures 
occurring  in  the  course  of  nerves  had  been  described  before  the  term 
Neuroma  came  to  be  applied  to  such.  Dr.  Eobert  Smith,  in  his  valuable 
and  elaborate  memoir,  makes  a  brief  reference  to  the  early  history  of 
the  subject;2  and  so  likewise  does  Mr.  William  Wood,  in  his  important 
papers  entitled,  "Observations  on  painful  Subcutaneous  Tubercle," 
and  "On  NSuroma."3  The  famous  English  surgeon,  William  Cheselden, 

1  The  Nature  and  Treatment  of  Gout  and  Rheumatic  Gout,  p.  517. 
*  A  Treatise  on  the  Pathology,  Diagnosis,  and  Treatment  of  Neuroma.  Dublin,  1849. 
5  Transactions  of  the  Medico-Chirurgical  Society  of  Edinburgh,  vol.  iii.  pp.  317 
and  367. 


NEURITIS   AND    NEUROMA.  123 

is  specially  mentioned  as  having  given  the  first  accurate  account  of 
the  nervous  tubercle,  which  has  become  familiar  chiefly  through  the 
writings  of  Mr.  wood.  "Immediately  under  the  skin,  upon  the  shin 
bone,  I  have  twice  seen  little  tumours,  less  than  a  pea,  round  and 
exceeding  hard,  and  so  painful  that  both  cases  were  judged  to  be 
cancerous:  they  were  cured  by  extirpating  the  tumour.  But  what  was 
more  extraordinary  was  a  tumour  of  this  kind,  under  the  skin  of  the 
buttock,  small  as  a  pin's  head,  yet  so  painful  that  the  least  touch  was 
insupportable,  and  the  skin  for  half  an  inch  round  was  emaciated: 
this,  too,  I  extirpated  with  so  much  of  the  skin  as  was  emaciated,  and 
some  fat.  The  patient,  who  before  the  operation  could  not  endure  to 
set  his  leg  to  the  ground,  nor  turn  in  his  bed  without  exquisite  pain, 
grew  immediately  easy,  walked  to  his  bed  without  any  complaint,  and 
was  soon  cured."  The  same  writer  describes  and  figures  the  cystic 
neuroma.  "  A  tumour  formed  in  the  centre  of  the  cubital  (ulnar) 
nerve,  a  little  above  the  bend  of  the  arm ;  it  was  of  the  cystic  kind, 
but  contained  a  transparent  jelly;  the  filaments  of  the  nerve  were 
divided  and  ran  over  its  surface.  This  tumour  occasioned  a  great 
numbness  in  all  the  parts  that  nerve  leads  to,  and  excessive  pain  upon 
the  least  touch  or  motion.  This  operation  (for  the  removal,  of  the 
tumour)  was  done  but  a  few  weeks  since;  the  pain  is  entirely  ceased, 
the  numbness  a  little  increased,  and  the  limbs  as  yet  not  wasted."1 

The  term  Neuroma,  or  rather  Neuromes,  was  first  employed  by  M. 
Odier  of  Geneva.  "  Enfin,"  writes  Odier,  "  on  peut  donner  le  nom  de 
Neuromes  a"  ces  turneurs  mobiles,  circonscrites  et  profondes,  qui  sont 
produites  par  le  gonflement  accidentel  d'un  nerf,  a  I'extre'rnite  duquel 
la  compression  de  la  turneur  fait  e"prouver  des  crampes  tres  penibles."2 

There  have  been  various  classifications  of  neuromatous  tumours 
attempted  by  pathologists,  such  as  local  and  general — that  is,  as  affecting 
one  nerve,  or  several  nerves;  and,  again,  those  which  are  the  direct 
consequence  of  a  morbid  process,  and  those  resulting  from  an  original 
vice  of  conformation.  Dr.  Smith,  rejecting  these  divisions,  has  sug- 
gested, as  sufficient  for  practical  purposes,  that  Neuromata  should  be 
considered  as  of  two  kinds:  1st,  of  spontaneous  origin,  or  Idiopathic; 
2d,  as  the  result  of  wounds  or  other  injuries  of  the  nerves,  and  there 
fore  Traumatic. 

Before  offering  a  brief  description  of  these  varieties,  it  may  be  well 
to  direct  attention  a  little  more  fully  to  the  painful  subcutaneous  tubercle, 
which  we  have  the  authority  of  Dr.  Hughes  Bennett  and  other  patho- 
logists for  stating  "  must  be  referred  to  this  class  of  tumours,"3  that  is, 
neuromatous  fibrous  tumours. 

"Although,"  remarks  Dr.  Smith,  "  pathologists  have  hitherto  failed 
to  discover  anything  like  nervous  structure  in  these  tumours,  I  still 
incline  to  the  opinion  that  they  are  connected  with  the  minute  fila- 
ments and  ultimate  ramifications  of  the  nerves.  Upon  any  other  sup- 

1  The  Anatomy  of  the  Human  Body,  12th  edit.,  London,  1784,  pp.  136  and  256. 

2  Manuel  de  Med«cine.     Pratique  ou  Somniaire  d'un  Cours  gratuit,  donn6  en  1800, 
1801,  et   1804,  aux  Officiers  de  Saute  du  departeiuent  du  Leuiau,  par  Louis  Odier, 
Paris,  1811,  p.  362. 

3  Clinical  Lectures  on  the  Principles  and  Practice  of  Medicine.     3d  edit.  p.  171. 


DISEASES    OF    THE    NERVES. 

position  it  is,  I  conceive,  impossible  to  offer  a  rational  explanation  to 
account  for  the  dreadful  severity  of  the  sufferings  which  they  induce." 
Mr.  Paget,  who  has  carefully  examined  the  "painful  subcutaneous 
tumours,"  describes  them  as  being  formed  of  "either  fibre-cellular  or 
fibrous  tissue,  in  either  a  rudimental  or  a  perfect  state."  Alluding  to 
a  case  described  by  the  late  Professor  Miller,  in  his  "  Principles  of 
Surgery,"  and  by  Professor  Bennett,  the  same  pathologist  admits  that 
their  structure  may  sometimes  be  fibro-cartilaginous.1 

Of  this  affection  the  first  detailed  account  was  given  by  the  late 
Mr.  William  Wood,  of  Edinburgh.  After  the  publication  of  Mr, 
Wood's  earlier  papers,2  cases  were  recorded  by  different  observers,  and 
in  1829  an  instructive  resume  of  the  whole  subject  was  laid  by  him 
before  the  Medico- Chirurgical  Society  of  Edinburgh,  and  appeared,  as 
already  mentioned,  in  its  "Transactions." 

This  disease  consists  in  the  formation  of  a  small  lump  or  tubercle 
seated  in  the  subcutaneous  cellular  tissue,  immediately  under  the 
integuments,  which  retain  their  natural  appearance.  The  tubercle  is 
met  with  in  different  parts  of  the  body,  but  most  frequently  in  the 
extremities.  It  is  extremely  small,  pisiform  in  shape,  of  firm  con- 
sistence, and  apparently  quite  circumscribed. 

The  characteristic  feature  of  the  disease  is  the  occurrence  of  violent 
pain  coming  on  paroxysmally.  The  paroxysms  vary  in  duration  from, 
ten  minutes  to  upwards  of  two  hours,  their  frequency  as  well  as 
intensity  appearing  to  increase  in  precise'relation  to  the  length  of  time 
the  disease  has  existed.  Some  patients  enjoy  intervals  of  relief  from 
pain  for  days  or  even  weeks,  while  others  have  repeated  attacks  in  the 
course  of  a  single  day.  The  paroxysms  of  pain  frequently  occur  when 
the  patient  has  fallen  asleep.  They  are  also  apt  to  be  excited  by 
various  external  causes,  such  as  pressure  and  blows;  while  in  rarer 
instances  mental  disquietude  and  atmospheric  changes  have  been  their 
only  apparent  occasion. 

Females  are  more  frequently  the  subjects  of  this  disease  than 
males.  Wood,  referring  to  thirty-five  cases  collected  by  him,  mentions 
that  twenty-eight  were  females,  five  males;  and  in  the  account  of  two 
the  sex  was  not  stated.  Of  thirteen  cases  quoted  by  Descot,  ten  oc- 
curred in  females,  and  three  in  males.  Rornberg  has  met  with  three 
instances,  all  in  females. 

The  situation  of  the  tubercle  in  the  thirty-five  cases  referred  to  by 
Wood  was  as  follows:  in  the  lower  extremities  in  twenty-two,  in  the 
upper  extremities  in  eleven,  in  the  chest  in  one,  and  in  one  in  the 
scrotum.  In  only  two  of  these  cases  was  there  more  than  one 
tubercle  present. 

This  disease  does  not  seem  .to  be  intimately  connected  with  any 
particular  period  of  life,  as  it  has  been  noticed  at  all  ages  from  thirteen 
to  above  seventy. 

"It  is  a  happy  circumstance  that  this  very  painful  affection  is  capa- 
ble of  being  remedied  by  a  very  simple  operation.  The  tubercle  is 

1  Lectures  on  Surgical  Pathology,  vol.  ii.  p.  123. 

2  The  Edinburgh  Medical  and  SurgicalJournal,  1812.    Two  articles,  pp.  285  and  429. 


NEURITIS   AND    NEUROMA.  125 

easily  removed  by  a  single  incision,  and  it  is  unnecessary  to  take 
away  any  portion  of  the  integuments,  or  of  the  surrounding  cellular 
tissue.  No  bad  effect  can  follow  the  removal  of  the  little  body." — 
Wood. 

Although  this  subcutaneous  tubercle  has  been  considered  as  a 
variety  of  Neuroma,  it  must  be  held  in  remembrance  that,  its  distinct 
connection  with  branches  of  nervous  trunks  never  having  been  deter- 
mined, this  is  more  a  matter  of  inference  than  of  demonstration. 
Ollivier  and  Rayer  together  carefully  dissected  the  tumour  in  a  case 
to  which  reference  is  made  in  his  latest  paper  by  Wood,  and  the 
result  is  thus  expressed :  "  Exterieurement  il  etait  enveloppe  de  tissu 
cellulaire,  dans  lequel  nous  ne  pumes  distinguer  aucun  filet  nerveux, 
meme  &  1'aide  d'une  forte  loupe."1  Paget  remarks  that  the  general 
opinion  is  against  the  supposition  of  the  intimate  connection  of  these 
painful  tumours  with 'nerves.  "Dupuytren,"  he  writes,  "says  that  he 
dissected  several  of  these  tumours  with  minute  care,  and  never  saw 
the  smallest  nervous  filament  adhering  to  their  surface.  I  have  sought 
them  with  as  little  success  with  the  microscope.  Of  course  I  may 
have  overlooked  nerve-fibres  that  really  existed.  It  is  very  hard  to 
prove  a  negative  in  such  cases  ;  and  cases  of  genuine  Neuroma,  i.e.,  of 
a  fibrous  tumour  within  the  sheath  of  a  nerve,  do  sometimes  occur, 
which  exactly  imitate  the  cases  of  painful  subcutaneous  tumour." 

We  have  now  to  consider  the  first  of  the  two  forms  of  Neuroma,  as 
distinguished  by  Smith,  and  now  generally  recognized,  namely,  the 
Idiopathic  Neuroma.  Tumours  of  this  nature  are  of  an  oval  or  oblong 
form,  their  long  axis  corresponding  with  the  direction  of  the  nerve  to 
which  they  are  attached.  They  vary  considerably  in  size.  One 
figured  in  his  work  by  Smith  is  as  small  as  a  grain  of  wheat,  while 
another  is  as  large  as  a  good-sized  melon.  Between  these  two  ex- 
tremes every  variety  of  size  occurs.  There  may  be  only  one,  or 
several  may  be  found  on  the  same  nerve ;  occasionally  they  are  found 
simultaneously  upon  all  the  spinal  nerves.  "In  number,"  says  Roki- 
tansky,  "they  vary  from  one  until  they  are  almost  countless."  A  re- 
markable general  disease  is  thus  constituted,  of  which  three  cases 
have  been  observed  in  the  Vienna  Hospital.  Neuromata  are  com- 
paratively rare  in  the  ganglionic  system.  But  although  occurring 
most  frequently  on  the  spinal  nerves,  neuroma  is  not  limited  to  them; 
the  cerebral  nerves,  motor  as  well  as  sensory,  particularly  those  most 
closely  resembling  the  nerves  of  the  cord,  present  at  times  the  same 
tumours. 

In  general,  neuromata  are  solid  throughout  their  entire  structure 
but  in  some  instances  are  of  cystic  formation,  as  in  the  case  recorded 
by  Cheselden,  and  already  referred  to.  These  tumours  are  of  slow 
growth,  but  continue  to  undergo  a  steady  increase  in  size,  although 
many  years  may  elapse  before  they  attain  such  dimensions  as  to 
prove  a  source  of  serious  inconvenience.  They  are  movable  in  the 
transverse  direction,  but  not  in  the  course  of  the  nerve  upon  which 

1  Traite  thforetique  et  pratique  des  Maladies  de  la  Peau,  seconde  ddit.,  t.  ii.  p. 
290.  Paris,  1835. 


126  DISEASES    OF    THE    NERVES. 

they  are  seated.  There  may  be  a  difficulty  in  distinguishing  tumours 
which  are  merely  contiguous  to  nerves  from  the  true  Neuroma,  hav- 
ing its  origin  within  the  neurilemma.  Wood  has  specially  alluded 
to  this  difficulty  in  diagnosis,  and  Smith  has  pointed  out  that  the  non- 
nervous  tumours,  unlike  Neuromata,  are  generally  movable  in  all 
directions,  and  when  drawn  away  from  the  nerve,  cease  to  be  painful 
on  pressure. 

Nerve  tumours  are  described  by  Rokitansky  as  lying  between  the 
fasciculi  of  the  nerves,  and  interwoven  with  their  neurilernmatous 
sheath.  Neuroma,  the  same  pathologist  observes,  is  never  deposited 
in  the  centre  of  a  nerve,  but  at  its  side,  so  that  only  a  small  part  of  its 
fasciculi  is  displaced ;  the  displaced  fasciculi  are  spread  abroad  and 
stretched  over  the  tumour,  while  the  greater  mass  of  the  nerve  remains 
on  the  other  side  uninjured,  and  with  its  fibres  in  connection  with  one 
another. 

The  solid  neuromatous  swellings  are  of  a  tough  elastic  consistence, 
of  grayish  or  pale  yellowish-red  colour,  and  are  invested  with  a  dis- 
tinct fibrous  sheath.  Dr.  Hughes  Bennett  thus  describes  them  :  "  On 
being  minutely  examined,  they  are  found  to  consist  of  fibrous  texture 
more  or  less  dense,  the  filaments  often  arranged  in  wavy  bundles  run- 
ning parallel  to  each  other,  but  occasionally  assuming  a  looped  form, 
or  intercrossing  with  each  other.  I  have  also  found  them  to  contain 
groups  of  cells.  Not  unfrequently  they  are  fibro-cartilaginous;  some- 
times with  the  cells  closely  aggregated  together,  and  at  others  widely 
scattered.  In  some  of  the  neuromatous  swellings  described  by  Dr. 
Smith  I  found  the  fibrous  tissue  to  present  wavy  bundles,  among 
which  a  few  granule  and  cartilage  cells  were  scattered  and  shrivelled, 
apparently  from  the  action  of  spirit."1 

Neuromata  seldom  contract  adhesion  to  the  investing  integuments, 
unless  they  have  been  subjected  to  continued  pressure.  Smith  has 
never  known  them  to  suppurate,  or  to  be  removed  b*y  absorption. 
Pain  has  been  generally  considered  to  be  a  characteristic  feature  of 
neurornatous  swellings.  In  this  respect,  however,  there  is  infinite 
variety.  AVhen  a  single  Neuroma  exists,  there  is  almost  invariably 
much  suffering.  The  pain,  moreover,  occurs  suddenly  and  paroxysm- 
ally,  darting  along  the  nerve  with  the  violence  and  instantaneousnesa 
of  an  electric  shock.  On  the  other  hand,  in  those  examples  of  Neu- 
roma which  are  distinguished  by  the  number  of  the  tumours  it  is  not 
uncommon  to  find  these  occasioning  little  or  no  inconvenience  to  the 
patient. 

It  is  exceedingly  difficult  to  determine  with  anything  like  exact- 
ness the  real  cause  of  the  paroxysmal  attacks  and  sudden  aggravation 
of  severe  pain  which  occur  in  this  as  well  as  in  many  other  forms  of 
disease  of  the  nervous  system.  Mental  emotions  and  the  ordinary 
atmospherical  vicissitudes  have  been  generally  assigned  as  the  occasion 
of  these  occurrences  in  Neuroma. 

Paget  has  some  very  interesting  observations  on  the  cause  of  pain  in 

1  Loc.  cit.,  p.  171. 


NEURITIS    AND   NEUROMA.  127 

Neuroma,  as  well  as  on  the  nearly  entire  absence  of  all  suffering  which 
has  been  noticed  in  some  cases;  and  founding  on  the  observations  of 
Smith  and  others,  including  himself,  this  excellent  writer  is  no  doubt 
correct  when  he  states,  "that  we  cannot  assign  the  pain  in  these  cases 
entirely  to  an  altered  mechanical  condition  of  nerve-fibres  in  or  near 
the  tumour.  We  must  admit,  though  it  be  a  vague  expression,  that 
the  pain  is  of  the  nature  of  that  morbid  state  of  the  nerve  force  which 
we  call  neuralgic.  Of  the  exact  nature  of  this  neuralgic  state,  indeed, 
we  know  nothing ;  but  of  its  existence  as  a  morbid  state  of  nerve-force, 
or  nervous  action,*  we  are  aware  in  many  cases  in  which  we  can  as  yet 
trace  no  organic  change,  and  in  many  more,  in  which  the  sensible  or- 
ganic change  of  the  nerves  is  inadequate  to  the  explanation  of  the 
pain  felt  through  them."  In  short,  Paget  argues  for  the  pain  being 
functional,  and  not  necessarily  dependent  at  least  on  an  organic 
disorder.  If  such  pain  is  found  to  be  influenced  by  the  remedies 
chiefly  available  for  the  relief  of  ordinary  neuralgia — quinine,  iron 
arsenic,  belladonna,  stramonium,  the  bromide  of  potassium — this  sug 
gestion  will  receive  corroboration. 

We  now  know  that  such  Neuromata  as  are  the  seat  of  severe  pain 
and  of  continual  irritation  may  give  rise  to  attacks  of  the  so-called 
sympathetic  epilepsy.  Instances  of  this  nature  are  to  be  found  in 
the  writings  of  several  authors,  and  it  is  sufficient  here  to  refer  to  the 
well-known  views  of  Brown-Sequard  respecting  the  exciting  causes 
of  the  epileptic  convulsion,  and  of  many  other  nervous  affections.1 

In  the  idiopathic  form  of  Neuroma  the  pain  is  generally  limited 
to  the  parts  below  the  tumour ;  and  the  sign  of  the  true  Neuroma, 
signalized  by  Aransoohn,  has  been  accepted  by  others — namely,  that 
when  the  trunk  of  the  nerve  is  compressed  above  the  tumour  the  pain 
ceases,  and  then  the  Neuroma,  previously  acutely  sensitive,  can  be 
touched  without  any  uneasiness  being  caused.  The  remark  already 
made  as  to  the  solid  variety  of  Neuroma  not  being  necessarily  painful 
applies  likewise  to  the  fluid  or  cystic  tumour. 

Our  knowledge  of  the  determining  causes  of  Neuroma  cannot  be  said 
to  have  advanced  since  the  period  when  the  important  treatise  of 
Dr.  Smith  first  appeared,  and  we  are  still  compelled  to  adopt  his 
expression,  "I  feel  it  must  be  confessed  that  we  know  nothing  with 
certainty  regarding  the  causes  of  Neuroma."2 

Neuromatous  tumours  have  been  frequently  removed  along  with 
the  corresponding  portion  of  the  nerve  on  which  they  were  situated  ; 
and  such  operations,  while  entirely  relieving  the  patients  from  suffering, 
have  not  been  succeeded  by  any  considerable  loss  of  sensibility,  or  of 
the  power  of  voluntary  movement,  in  the  parts  supplied  by  even  large 
nerves. 

The  sciatic  nerve  may  be  divided,  as  in  a  case  of  severe  neuralgia 
of  that  nerve,  by  M.  Malagodi,  and  a  portion  of  it  excised,  without 
permanently  destroying  the  functions  of  the  limb. 

1  Researches  on  Epilepsy,  p.  35  ;  also  Course  of  Lectures  on  the  Physiology  and 
Pathology  of  the  Central  Nervous  System,  p.  181.  Article,  Neuroma,  by  the  sauia 
Author,  in  Holmes's  System  of  Surgery,  vol.  iii.  p.  896. 

8  Loc.  cit. ,  p.  5. 


128  DISEASES    OF    THE    NERVES. 

The  magnitude  of  the  nervous  trunk,  which  is  the  seat  of  the 
disease,  will  of  course  largely  determine  the  period  at  which  complete 
or  partial  restoration  of  the  function  in  the  limb  is  established.  In 
some  cases  a  few  months,  in  others  a  year  and  upwards,  have  elapsed ; 
but  sooner  or  later,  in  all  recorded  instances,  the  banished  sensibility 
and  motor  power  have  been  regained. 

The  interference  with  the  calorific  function  of  the  nervous  system 
is  strikingly  exhibited  in  cases  of  operation  for  Neuroma.  Mr.  Adams 
and  Dr.  Smith  have  drawn  attention  to  the  diminution  of  temperature 
in  the  limb  after  the  removal  of  the  tumour,  and  with  it  a  portion  of 
nerve — a  diminution  readily  noticed  both  by  patients  and  operator, 
and  which  has  lasted  for  a  lengthened  period,  even  after  the  restoration 
of  the  other  functions. 

It  may  then  be  concluded  that  when  idiopathic  Neuroma  is  seated 
in  the  hand,  forearm,  or  upper  arm  (the  positions  in  which  it  has 
most  commonly  been  found),  the  operation  for  removal  may  be  safely 
practised.  It  is  possible  that  a  similar  plan  might  be  adopted  in  the 
case  of  Neuroma  in  the  lower  extremity ;  but  it  is  on  record  that 
amputation  of  the  limb  has  been  had  recourse  to  by  Chelius,  in  a 
case  of  nervous  tumour  occupying  the  popliteal  space  and  stretching 
to  nearly  the  centre  of  the  back  of  the  thigh.  This  was  an  illustra- 
tion; and  there  are  others  which  teach  a  similar  lesson,  of  the  disease 
having  been  permitted  to  attain  a  very  large  size — so  large  as  to  pre- 
vent any  attempt  being  made  for  its  simple  removal. 

TRAUMATIC  NEUROMA. — Under  this  division  are  to  be  included 
tumours  of  nerves  resulting  from  any  form  of  mechanical  injury,  such 
as  wounds,  blows,  pressure,  or  following  amputation. 

Traumatic  Neuroma  is  almost  invariably  single.  The  tumour  is 
the  seat  of  intense  pain,  which,  unlike  the  suffering  in  the  idiopathic 
form  of  the  disease,  is  not  confined  to  the  growth  itself,  or  felt  merely 
by  the  parts  below  it,  but  is  frequently  found  extending  along  the 
nerve  towards  its  origin.  When  Neuroma  occurs  as  a  consequence  of 
a  wound  of  nerve,  it  usually  consists  of  a  solid  tumour,  not  invested 
in  neurilemma,  and  destitute  of  any  distinct  capsule.1  It  is  most 
likely  to  form  when  the  nervous  cord  has  been  cut,  but  not  entirely 
divided ;  and  cases  of  this  nature  are  even  more  than  ordinarily  pain- 
ful. 

The  following  case  is  published  by  Mr.  Wood  in  his  "  Memoir  on 
Neuroma ;"  it  occurred  in  the  practice  of  Mr.  Syrne: — 

"James  Muir,  aged  43.  30th  June,  1828. — On  the  inner  side  of 
the  left  knee,  about  a  hand-breadth  above  the  joint,  there  is  a  narrow 
depressed  cicatrix,  two  inches  long.  Between  this  cicatrix  and  the 
sartorius  there  is  a  small  tumour,  about  the  size  of  an  almond,  and  of 
very  firm  consistence.  When  the  limb  is  extended,  this  tumour  can 
hardly  be  perceived,  being  then  overlapped  by  the  sartorius;  but 
when  the  knee-joint  is  bent,  it  can  be  felt  very  distinctly.  It  is  most 
movable  in  a  lateral  direction,  but  seems  pretty  firmly  connected  to 
the  subjacent  parts  by  condensed  cellular  substance. 

1  Smith,  loc.  cit.,  p.  20. 


NEURITIS    AND   NEUROMA.  129 

"  The  patient  states  that  the  tumour  is  always  painful  when  pressed, 
but  is  more  so  at  one  time  than  another.  The  pain  is  not  confined 
to  the  part,  but  shoots  all  over  the  knee,  and  sometimes  exten 
the  jrroin  to  the  toes.  He  observes  that  thenaif>--L^^rt^r 
during  «old  or  damp  weather.  JkJrea»~~**J^w^ys  together,  pre- 
vents him  fr0rn  walking,  or  even  resting  on  the  limb.  His  story  is, 
that  when  a  b^y,  about  eleven  years  old,  he  strained  his  knee  by 
jumping  into  a  saw-pi^  which  led  to  the  formation  of  a  large  abscess 
that  opened  on  both  sides  of  the  knee,  namely,  at  the  part  where  the 
cicatrix  above  mentioned  still  remains,  and  exactly  opposite,  where 
also  there  is  a  similar  cicatrix.  Several  small  bits  of  bone  were  dis- 
charged, and  at  the  end  of  two  years  he  got  quite  well.  For  the 
following  twenty-seven  years  he  led  an  active  life ;  ten  of  them  were 
spent  in  a  militia  regiment.  About  eight  years  ago  he  strained  his 
knee  while  walking  in  his  garden,  and  thereafter  became  subject  to 
flying  pains  about  the  joints.  These  pains  induced  him  to  rub  the 
knee  frequently ;  and  in  doing  so,  about  two  years  ago,  he  noticed  the 
tumour.  It  was  then  the  size  of  a  pea,  and  has  gradually  enlarged. 
The  disagreeable  symptoms  also  have  become  greatly  aggravated; 
and,  as  he  refers  them  all  to  the  tumour,  he  is  desirous  of  having  it 
removed. 

"  12/!/i  July. — Mr.  Wood  (continues  Mr.  Syme),  who  was  kind 
enough  to  examine  the  patient,  having  agreed  with  me  that  the 
tumour  was  seated  on  or  in  the  nervus  saphenus,  and  that  it  ought 
to  be  removed,  I  performed  the  operation,  with  his  assistance,  on  the 
1st  of  July. 

"The  tumour  being  divided  showed  a  firm  fibrous  capsule  contain- 
ing a  soft  brownish-white  pulpy  matter.  The  nerve  was  traced  into 
the  tumour,  but  not  through  it.  The  patient  made  a  good  recovery, 
and  remains  free  from  his  complaint."1 

The  foregoing  case  illustrates  the  proper  treatment  of  Traumatic 
Neuroma,  which  is  to  excise  the  tumour  with  the  corresponding  por- 
tion of  nerve,  in  every  case  when  its  situation  will  permit  of  this 
being  done.2 

The  last  form  of  Neuroma  which  requires  any  separate  consideration 
is  that  succeeding  to  amputations.  Smith  remarks  in  regard  to  such, 
that  "  their  existence  is  so  constant  that  we  may,  perhaps,  consider 
them  as  representing  the  normal  condition  of  the  ends  of  the  nerves 
in  stumps."  Generally  they  cause  no  uneasiness  whatever ;  but  on 
the  other  hand,  they  have  occasionally  been  the  occasion  of  severe 
neuralgia,  occurring  in  paroxysms  of  great  length. 

The  Neuroma  of  stumps  varies  in  size,  being  in  some  instances 
not  larger  than  a  garden-pea,  in  others  as  large  as  a  grape,  or  even 
plum.  Such  Neuromata  are  generally  of  an  oval  or  oblong  form,  of 
grayish-white  color,  and  of  a  firm  dense  texture. 

The  situation  of  the  Neuroma  in  the  stump  is  not  always  the  same; 
it  may  be  several  inches  above  the  surface  of  the  latter,  and  be 

1  Loc.  cit.,  p.  426.  2  Smith,  p.  22. 

9 


130  DISEASES    OF    THE    NERVES. 

connected  with  the  cicatrix  by  means  only  of  a  fibrous  cord,  itself 
destitute  of  any  nervous  structure. 

It  is  the  opinion  of  some  pathologists,  that  the  Neuromata,  succeed- 
!i!^  "~~£"lfqt,ion  are  produced  by  the  pressure  which  is  exerted  upon 
the  surface  ol  me  B_r  An  objection  fatai  to  this  explanation,  how- 
ever, has  been  advanced— namely,  that  in  many  stumps  ^nich  have 
never  been  subjected  to  pressure  these  little  tumours  ^  found. 

Dr.  Smith  believes  their  formation  to  be  for  ttc  protection  of  the 
extremity  of  the  nerve. 


NEURALGIA.  131 


IV. 
NEURALGIA. 

BY  FRANCIS  EDMUND  ANSTIE,  M.D.,  F.R.C.P. 

DEFINITION. — A  disease  of  the  nervous  system  manifesting  itself 
by  pains,  nearly  always  unilateral,  which  appear  to  follow  the  course 
of  particular  sensory  nerves.  The  pains  are  usually  sudden  in  their 
commencement,  and  of  a  darting,  stabbing,  boring,  or  burning 
character;  they  are  at  first  unattended  with  any  local  change  which 
can  be  recognized,  or  by  any  constitutional  pyrexia.  They  are  always 
markedly  intermittent ;  sometimes  regularly  and  sometimes  irregularly 
so.  The  periods  of  intermission  are  distinguished  by  complete  free- 
dom from  acute  suffering,  and  in  recent  cases,  the  patient  appears 
quite  well  at  these  times.  In  old-standing  cases,  however,  persistent 
tenderness  and  other  signs  of  local  mischief  are  apt  to  be  developed 
in  the  tissues  which  surround  the  distribution  of  the  nerves  which  are 
the  seat  of  the  acute  pains.  Severe  attacks  of  Neuralgia  are  usually 
complicated  with  secondary  affections  of  other  nerves  which  are 
intimately  connected  with  that  which  is  the  original  seat  of  pain;  and 
in  this  way  congestion  of  bloodvessels,  hypersecretion,  or  arrested 
secretion  from  glands,  inflammation  and  ulceration  of  tissues,  &c.,  are 
sometimes  brought  about. 

SYNONYMS. — The  word  Neuralgia  has  a  generally  recognized  force, 
and  there  is  no  equivalent  to  it  (except  foreign  variations  in  mere 
terminology)  which  represents  the  whole  group  of  disorders  to  which 
it  applies,  though  there  are  numerous  phrases  for  particular  forms  of 
the  disorder. 

CLINICAL  HISTORY  AND  SYMPTOMS. — These  vary  so  greatly  in  dif- 
ferent cases  of  Neuralgia  that  it  will  be  necessary  to  discuss  the 
greater  part  of  this  subject  under  the  headings  of  the  special  varieties 
of  the  disease.  There  are  certain  features,  however,  which  are  ob- 
served in  all  true  Neuralgias. 

In  the  first  place,  it  is  universally  the  case  that  the  existing 
condition  of  the  patient  at  the  time  of  the  first  onset  of  the  disease  is 
one  of  debility,  either  general  or  special.  I  make  this  statement 
with  great  confidence,  notwithstanding  the  contrary  assertion  ad- 
vanced by  so  high  an  authority  as  Valleix,  whose  able1  treatise  really 
laid  the  foundation  for  all  our  accurate  knowledge  of  the  Neuralgias. 

1  Traits  des  Nevralgies.     Paris,  1841. 


132  DISEASES    OF    THE    NERVES. 

In  the  first  place,  it  is  certainly  the  case  that  the  larger  half  of  the 
total  number  of  patients  coming  under  my  care  with  various  forms  of 
Neuralgia  are  either  decidedly  anasmic  or  have  recently  undergone 
some  exhausting  illness  or  fatigue:  and  the  reason  why  Valleix  did 
not  find  so  many  cases  of  this  type  among  his  neuralgic  patients  ap- 
pears certainly  to  be,  that  he  limited  the  neuralgic  class  of  diseases  by 
an  artificial  definition,  which  we  shall  have  to  reject  as  untenable. 
On  the  other  hand,  although  a  considerable  number  of  neuralgic 
patients  are  so  far  healthy  in  appearance,  that  they  have  a  fairly 
ruddy  complexion  and  a  good  amount  of  muscular  strength,  it  is 
impossible  to  admit  that  these  facts  disprove  the  existence  of  debility, 
either  structural  or  functional,  in  the  nervous  system,  for  the  commonest 
experience  teaches  that  such,  debility  does  not  frequently  coexist  with 
a  great  robustness  and  development  of  the  apparatus  of  vegetation 
and  the  lower  forms  of  animal  function.  And  it  will  invariably  be 
found,  on  carefully  examining  these  apparently  robust  neuralgic  pa- 
tients, that  the  nervous  system  has  given  warnings  of  its  weakness ; 
thus,  the  patient  who,  after  an  exhausting  confinement,  attended  with 
great  loss  of  blood,  is  attacked  with  obstinate  claims  hystericus,  will 
inform  us  that  whenever  in  earlier  life  she  had  suffered  from  head- 
ache, the  pain  was  always  chiefly,  if  not  altogether,  confined  to  the 
nerves  which  are  now  the  seat  of  decided  Neuralgia.  In  a  large 
number  of  cases  I  have  also  found  that  the  attack  of  acute  pain  was 
immediately  ushered  in  by  a  remarkably  anaesthetic  condition  of  the 
parts  about  to  become  painful;  and  a  slighter  degree  of  blunted 
sensation  may  often  be  observed  in  the  intervals  between  the  earlier 
attacks  in  cases  of  Neuralgia.  In  -short,  I  have  never  seen  a  case  of 
neuralgic  pain  in  which  there  were  not  marked  evidences  of  nervous 
debility,  either  local  or  general. 

Another  circumstance  is  common  to  all  Neuralgias  of  superficial 
nerves;  and  as  a  large  majority  of  neuralgic  affections  are  superficial 
in  situation,  this  is,  for  practical  purposes,  a  general  characteristic  of 
the  disease.  I  refer  to  the  formation  of  tender  spots  at  various  points 
where  the  affected  nerves  pass  from  a  deeper  to  a  more  superficial 
level,  and  particularly  where  they  emerge  from  bony  canals,  or  pierce 
fibrous  fascia?.  So  general  is  this  characteristic  of  inveterate  cases, 
that  Valleix  founded  his  diagnosis  of  the  genuine  Neuralgias  on  the 
presence  of  these  painful  points,  in  which  assumption  I  think  there 
can  be  little  doubt  that  he  committed  an  error.1 

The  third  general  characteristic  of  neuralgic  affections  is,  that  the 
pain  is  intermittent,  or  at  the  least  remittent,  in  every  stage  of  the 
disease. 

The  fourth,  general  characteristic  is,  that  fatigue  and  every  other 
temporary  depressing  influence  directly  predisposes  to  an  attack  of 
acute  pain,  and  aggravates  it  when  already  existent. 

1  Trousseau  insists  with  much  energy  that  a  still  more  important "  point  douloureux" 
is  constantly  present  in  Neuralgia,  viz.  over  the  spinous  processes  of  one  or  more  ver- 
tebrae, corresponding  to  the  origin  of  the  painful  nerve.  It  is  true  (as  the  Brothers 
Griffin  had  long  before  pointed  out),  that  there  is  tenderness  in  this  situation.  But 
this  "point  apophysaire"  is  not  always,  nor  frequently,  the  seat  of  spontaneous  pain. 


NEURALGIA.  133 

VARIETIES. — It  is  possible  to  classify  the  Neuralgias  upon  either  of 
two  systems:  first  (A),  according  to  the  constitutional  condition  of 
the  patient;  and,  secondly  (B),  according  to  the  situation  of  the 
affected  nerves.  It  will  be  necessary  to  follow  both  these  lines  of 
classification,  avoiding  repetitions  as  much  as  possible. 

(A)  In  considering  the  influence  of  constitutional  states  upon  the 
typical  development  of  Neuralgia,  it  will  be  convenient  to  commence 
with  (I)  the  group  of  cases  in  which  the  general  state  of  the  organism 
exerts  the  least  amount  of  effect.  This  is  the  case  where  the  pain  is 
the  result  of  direct  injury  to  the  nerve-trunk,  whether  by  external 
violence,  by  the  mechanical  pressure  of  a  tumour,  or  by  the  involve- 
ment of  a  nerve  in  inflammatory  or  ulcerative  processes,  spreading  to 
it  from  neighbouring  tissues.  As  regards  the  development  of  symp- 
toms, the  important  matters  are,  that  the  pain  in  these  cases  commences 
comparatively  gradually,  that  the  intermissions  are  usually  much  less 
complete,  and  that  the  pain  is  far  less  amenable  to  relief  from  remedies 
than  in  other  varieties  of  Neuralgia.  The  little  that  can  be  said  about 
the  form  which  is  dependent  upon  progressively  increasing  pressure 
or  involvement  of  a  nerve  in  malignant  ulcerations,  caries  of  bones, 
or  teeth,  &c.,  falls  under  the  heads  of  Diagnosis  or  Treatment,  and 
need  not  detain  us  here.  The  clinical  history  of  Neuralgia  from  ex- 
ternal violence,  however,  requires  separate  discussion. 

1.  Neuralgia  from  external  violence  may  be  produced  by  a  shock 
(as  of  a  fall,  a  railway  collision,  &c.),  which  gives  ajar  to  the  central 
nervous  system,  or  by  severe  mental  emotion,  operating  upon  the  same 
part  of  the  organism.     Under  either  of  these  circumstances  the  de- 
velopment of  the  affection  seldom  occurs  at  once,  but  ensues  after  a 
variable   interval,  during   which   the   patient  exhibits  symptoms  of 
general  depression,  with  loss  of  appetite  and  strength.     Sometimes 
vomiting,  and  even,  in  other  instances,  actual  paralysis  of  a  partial  and 
temporary  kind  occur.      When  once  developed  the  neuralgic  attacks 
are  undistinguishable  from  those  which  occur  from  causes  internal  to 
the  organism.     The  affection  is  usually  very  obstinate.     In  a  large, 
number  of  cases  the  nerve  or  nerves  affected  have  previously  shown 
signs   of  weakness,  by  a  tendency  to  painful  affection  in   depressed 
states  of  the  organism.     In  the  greater  number  of  instances,  as  far  as 
my  experience  goes,  it  is  the  fifth  cranial  nerve  which  becomes  neuralgic 
from  the  effects  of  central  shock.     Illustrative  cases  will  be  given  in 
the  sections  on  local  classification. 

2.  Neuralgia  from  direct  violence  to  superficial  nerves  is  produced 
either  by  cutting  or,  more  rarely,  by  bruising  wounds. 

Cutting  wounds  may  divide  a  nerve-trunk,  (a)  partially,  or  (3), 
completely. 

(a)  When  a  trunk-nerve  is  partially  cut  through,  neuralgic  pain 
commonly  occurs,  if  at  all,  immediately  on  the  receipt  of  the  injury. 
One  such  example  only  has  come  under  my  own  care,  but  many  others 
are  recorded.1  In  this  case  the  ulnar  nerve  was  partly  cut  through  with 
a  tolerably  sharp  bread-knife,  at  a  point  not  far  above  the  wrist;  partial 

1  Vide  Lancet,  186G. 


DISEASES    OF    THE    NERVES. 

nnossthesia  of  the  little  and  ring  fingers  was  induced,  but  at  the  same 
time  violent  neuralgic  pains  in  the  little  finger  came  on,  in  fits  recur- 
ring several  times  daily,  and  lasting  for  about  half  a  minute.  Treat- 
ment was  of  little  apparent  effect  in  promoting  cure,  though  opiates 
gave  temporary  relief,  as  did  the  local  use  of  chloroform.  The  attacks 
recurred  for  more  than  a  month,  long  after  the  original  wound  had 
healed  soundly;  and  for  a  long  time  after  this  pressure  on  the  cicatrix 
would  reproduce  the  attacks.  A  slight  amount  of  anaesthesia  still 
remained  when  I  last  saw  the  patient,  more  than  a  year  after  the 
injury. 

(0)  Complete  severance  of  a  nerve-trunk  is  a  sufficiently  common 
accident,  far  more  common  than  is  the  production  of  Neuralgia  from 
such  a  cause;  indeed,  so  marked  is  this  disproportion  between  the 
injury  and  the  special  result,  that  I  have  been  led  to  the  conclusion 
that  a  necessary  factor  in  the  chain  of  morbid  events  must  be  the 
existence  of  some  antecedent  peculiarity  of  organization  in  the  central 
origin  of  the  injured  nerve.  This  opinion  is  rendered  more  probable 
by  the  fact  that  the  consecutive  Neuralgia  is  not  unfrequently  situated 
not  in  the  injured  nerve  itself,  but  in  some  other  nerve  with  which  it 
has  intimate  central  connections.  Two  such  examples  are  recorded 
in  my  Lettsomian  Lectures,1  in  which  the  ulnar  nerve,  and  one  in 
which  the  cervico-occipital,  respectively,  were  completely  divided:  in 
all  three  instances  the  Neuralgia  was  developed  in  the  branches  of 
the  trigeminus.  In  all  the  cases  which  have  come  under  my  notice 
the  Neuralgia,  whether  direct  or  reflex,  set  in  at  a  particular  period, 
viz.,  after  complete  cicatrization  of  the  wound,  and  while  the  functions 
of  the  branches  on  the  peripheral  side  were  partly,  but  not  completely, 
restored.  The  same  obstinacy  and  rebelliousness  to  treatment  was 
noticed  as  in  other  instances  of  Neuralgia  from  injury. 

A  few  words  must  be  given  before  quitting  the  subject  of  Neuralgia 
from  wounds  of  nerves,  to  the  cases  in  which  a  foreign  body  lodges, 
with  more  or  less  laceration,  in  the  substance  of  a  nerve-trunk.  I 
have  never  seen  such  a  case;  but  many  instances  are  recorded  in 
which  most  violent  and  painful  Neuralgia  has  been  set  up  in  this  way. 
Not  unfrequently  the  irritation  produces  no  noticeable  effect  on  the 
nerve  actually  pressed  upon,  but  sets  up  Neuralgia  in  a  nerve  so  distant 
that  no  connection  is  suspected  between  the  neuralgic  pain  and  the 
original  accident.  The  removal  of  a  small  piece  of  glass,  or  such 
other  irritating  body  from  the  cicatrix  of  an  old  wound  has  in  several 
recorded  instances  put  an  end  to  neuralgic  pains  in  quite  another 
situation,  for  which  all  manner  of  remedies  had  long  been  tried. 
Sometimes  the  neuralgic  pain  has  been  accompanied  by  tissue 
degeneration  of  an  alarming  character,  and  these  have  likewise  ceased 
at  once  upon  the  removal  of  the  peccant  body  which  had  been  the 
unsuspected  source  of  the  evil. 

Neuralgias  which  result  from  some  local  injuries  of  so  peculiar  a 
character  as  gunshot  wounds  scarcely  fall  properly  within  the  province 
of  this  article.  The  reader  who  desires  to  know  all  that  can  be  said 

1  .Vide  Lancet,  1866. 


NEURALGIA.  135 

with  regard  to  this  particular  class  of  affections  is  recommended  to 
study  the  able  and  carefully  compiled  "  Report"  of  Messrs.  Mitchell, 
Morehouse,  and  Keen.1 

The  case  of  Neuralgia  from  injury,  pressure,  and  local  disease  of 
nerves  has  been  mentioned  first,  because  this  form  of  the  disease  is  less 
influenced  than  others  by  general  constitutional  states.  But  it  is  an 
erroneous  opinion,  however  common,  that  the  general  condition  of 
the  body  is  here  without  any  influence  on  the  development  of  the 
nerve-pain.  It  has  been  forcibly  urged,  by  Dr.  Brinton  and  Dr.  Hand- 
field  Jones  more  especially,  that  a  condition  of  general  bodily  vigour 
mitigates,  and  that  constitutional  debility  decidedly  aggravates,  these 
forms  of  Neuralgia;  and  rny  own  experience  gives  most  practical 
proof  of  the  justice  of  this  argument. 

(II.)  Neuralgias  of  intm-nervous  origin. — As  regards  the  constitutional 
conditions  with  which  the  several  varieties  of  Neuralgia  that  arise 
independently  of  external  violence,  or  disease  of  extra-nervous  tissues, 
are  respectively  allied,  the  following  preliminary  subdivision  may  be 
made : — 

1.  Neuralgia  of  malarious  origin. 

2.  Neuralgias  of  the  period  of  bodily  development. 
8.  Neuralgias  of  the  middle  period  of  life. 

4.  Neuralgias  of  the  period  of  bodily  decay. 

5.  Neuralgias  associated  with  anaemia  and  inal-nutrition. 

1.  Neuralgias  of  malarious  origin  were  formerly  far  more  prevalent 
than  they  are  at  present,  within  the  sphere  of  the  English  practitioner 
of  medicine;  with  the  general  decline  of  malarial  fevers,  consequent 
on  improved  drainage  and  cultivation  of  lands,  they  have  become 
constantly  more  scarce.  In  former  times,  on  the  contrary,  they  were 
so  common,  that  they  forced  themselves  on  the  notice  of  every  physi- 
cian. The  term  "brow-ague,"  to  this  day  applied  by  many  medical 
men  to  every  variety  of  supra-orbital  Neuralgia,  is  a  relic  of  the  older 
experience  on  this  point;  as  is  also  the  very  common  mistake  of  ex- 
pecting all  neuralgic  affections  to  present  a  distinctly  rhythmic  recur- 
rence of  symptoms. 

My  own  experience  of  malarial  Neuralgia  has  been  very  limited, 
and  I  may  as  well  say  all  that  I  know  of  its  symptoms  at  once.  In 
fact,  though  the  out-patient  practice  of  the  Chelsea  Dispensary  and 
Westminster  Hospital  has  afforded  me  a  considerable  number  of  ex- 
amples of  ague  in  past  years,  I  have  only  seen  two  undoubted  and  one 
doubtful  case  of  malarial  Neuralgia,  in  all  of  which  the  fifth  nerve  was 
affected.  The  periodicity  in  one  of  the  genuine  cases  was  regular 
tertian  ;  in  the  other  regular  quotidian.  An  algide  condition  always 
ushered  in  the  attacks ;  but  this  was  gradually  exchanged,  as  the  pain 
continued,  for  a  condition  in  which  the  pulse  was  rapid,  soft,  and 
bounding,  and  the  strength  was  further  depressed.  In  both  of  these 
cases  there  were  unilateral  flushing  of  the  face,  and  congestion  of  the 
conjunctiva,  to  a  slight  degree,  during  the  attack  of  pain.  The  pain 

1  Report  on  Gunshot  Injuries  to  Nerves,  observed  iu  the  late  American  War, 
Philadelphia,  18U4. 


136  DISEASES    OF    THE    NERVES. 

became  duller  and  more  diffused  contemporaneously  with  the  lowering 
of  arterial  pressure  (as  estimated  by  Marty's  Sphygmograph);  and 
after  the  disappearance  of  active  pain,  moderate  tenderness  over  a  con- 
siderable tract  around  the  course  of  painful  nerves  remained  for  some 
time.  But  there  was  no  distinct  development  of  ihe  painful  points  of 
Valleix  (to  be  hereafter  described),  a  circumstance  which  I  attribute 
to  the  rapid  cure  of  the  complaint,  in  each  instance,  by  quinine. 

2.  Neuralgias  of  the  period  of  bodily  development. — By  the  "  period  of 
bodily  development"  is  here  understood  the  whole  time  from  birth  up 
to  the  twenty-fifth  year,  or  thereabouts.     This  is  the  period  during 
which  the  organs  of  vegetative  and  of  the  lower  animal  life  are  con- 
solidating.    The  central  nervous  system  is  more  slow  in  reaching  its 
fullest  development,  and  the  brain  more  especially  is  many  years  later 
in  acquiring  its  maximum  of  organic  consistency  and  functional  power. 

That  portion  of  the  period  of  bodily  development  which  is  antece- 
dent to  puberty  is  but  little  obnoxious  to  neuralgic  affections.  From 
the  moment  when  puberty  arrives,  however,  all  is  changed.  In  the 
stir  and  tumult  which  pervades  the  organism,  and  especially  in  the 
enormous  diversion  of  its  nutritive  and  formative  nisus  to  the  evolution 
of  the  generative  organs  and  the  correlative  sexual  instincts,  the  deli- 
cate apparatus  of  the  nervous  system  is  apt  to  be  overwhelmed,  as 
well  as  left  behind,  in  the  race  of  development.  Under  these  circum- 
stances the  tendency  to  neuralgic  affections  rapidly  increases.  It  will, 
however,  be  seen  later  that  there  is  a  great  preponderance  of  particular 
varieties  of  the  disease  among  the  cases  occurring  during  this  period. 

3.  Neuralgias  of  the  middle  period  of  life. — By  this  period  is  meant 
the  time  included  between  the  twenty-fifth  and  about  the  fortieth  or 
the  forty-fifth  year.     It  is  the  time  of  life  during  which  the  individual 
is  subjected  to  the  most  serious  pressure  from  external  influences.     The 
men,  if  poor,  are  engaged  in  the  absorbing  struggle  for  existence  and 
for  the  maintenance  of  their  families ;  or,  if  rich  and  idle,  are  immersed 
in  dissipation,  or  haunted  by  the  mental  disgust  which  is  generated  by 
ennui.     The  women  are  going  through  the  exhausting  process  of  child- 
bearing,  and  supporting  the  numerous  cares  of  a  poor  household  in 
some  cases,  or  are  devoured  with  anxiety  for  a  certain   position  in 
fashionable  society  for  themselves  and  their  children,  or  again  they 
are  idle  and  heart- weary,  or  condemned  to  an  unnatural  celibacy. 
Very  often  they  are  both  idle  and  anxious. 

It  must  not  be  supposed  that  there  is  a  sharp  line  of  demarcation 
between  this  period  and  the  last :  nevertheless  it  will  be  seen,  when  we 
come  to  discuss  the  local  varieties  of  Neuralgia,  that  there  are  certain 
broad  differences  in  the  general  tendencies  of  the  two  epochs.  It  must 
be  noted  that  particular  Neuralgias,  which  are  first  manifested  in  the 
development  period,  frequently  recur,  under  special  provocation,  in 
the  period  of  middle  life. 

4.  Neuralgias  of  declining  bodily  vigour. — The  period  here  referred 
to  is  that  which   commences  with    the   first    indications  of  distinct 
physical  decay,  of  which  the  earliest  that  we  can  recognize  (in  persons 
who  are  not  cut  off'  by  special  diseases)  is  perhaps  the  tendency  to 
atheromatous  change  in  the  arteries.    The  earliest  development  of  this 


NEURALGIA.  137 

symptom  varies  very  considerably  in  date ;  but  whenever  it  occurs  it 
is  a  plain  warning  that  a  new  set  of  vital  conditions  has  arisen  ;  and 
especially  notable  is  its  connection  with  the  characters  of  the  neuralgic 
afl'ections  which  take  their  rise  after  its  commencement.  The  period 
of  declining  life  is  pre-eminently  the  time  for  severe  and  intractable 
Neuralgias.  Very  few  patients  indeed  are  ever  permanently  cured, 
who  are  first  attacked  with  Neuralgia  after  they  have  entered  upon 
what  may  be  called  the  "degenerative"  period  of  existence. 

Perhaps  a  separate  heading  should  be  reserved  for  those  Neuralgias 
which  are  the  heralds  of  locomotor  ataxy.  But  they  seem  naturally 
to  fall  under  the  present  class,  although  the  nervous  degeneration 
which  produces  them  is  chiefly  in  the  direction  of  sclerosis.  The 
character  of  these  pains  is  fully  described  in  the  article  on  Locomotor 
Ataxy. 

5.  Neuralgias  which  are  immediately  excited  by  anemia  or  mal- 
nutrition. Of  the  neuralgic  affections  which  can  be  ranked  within 
this  group,  the  sole  characteristic  worthy  of  note  here  is  the  circum- 
stances in  which  they  arise.  It  would  seem  that  conditions  of  anaemia 
and  mal-nutrition  simply  aggravate  the  tendencies  of  existing  weak 
portions  of  the  nervous  system  to  be  affected  with  pain ;  just  as  they 
notoriously  do  aggravate  lurking  tendencies  to  convulsion  and  spasms. 

(B.)  We  come  now  to  the  consideration  of  local  varieties  of  Neu- 
ralgia. The  primary  subdivision  of  these  may  be  made  as  follows  : — 

(I.)  Superficial  Neuralgias.  (II.)  Visceral  Neuralgias.  The  super- 
ficial Neuralgias  may  be  subdivided  thus: — 

(a)  Neuralgia  of  the  fifth  (trifacial  or  trigeminal). 

(b)  Cervico-occipital  Neuralgia. 

(c)  Cervico-brachial  Neuralgia. 

(d)  Intercostal  Neuralgia. 

(e)  Lumbo-abdominal  Neuralgia. 
(/)  Crural  Neuralgia. 

(g)  Sciatic  Neuralgia. 

This  classification  is  taken  from  Valleix,  and  appears  to  me  sub- 
stantially correct. 

(a)  The  most  important  group  of  Neuralgias  are  those  of  the  fifth 
cranial  nerve. 

Neuralgia  of  the  fifth  nerve  always  exhibits  itself  with  especial 
violence  in  certain  foci,  which  Valleix  was  the  first  to  define  with 
accuracy.  These  foci  are  always  in  points  where  the  nerve  becomes 
more  superficial,  either  in  turning  out  of  a  bony  canal,  or  in  pene- 
trating fascias.  In  the  ophthalmic  division  of  the  nerve  the  following 
possible  foci  are  noticeable :  (1)  the  supra-orbital,  at  the  notch  of  that 
name,  or  a  little  higher  in  the  course  of  the  frontal  nerve ;  (2)  the 
palpebral,  in  the  upper  eyelid;  (3)  the  nasal,  at  the  point  of  emergence 
of  the  long  nasal  branch,  at  the  junction  of  the  nasal  bone  with  the 
cartilage;  (4)  the  ocular,  a  somewhat  indefinite  focus  within  the  globe 
of  the  eye;  (5)  the  irochlear,  at  the  inner  angle  of  the  orbit. 

In  the  superior  maxillary  division  the  following  foci  may  be  found  : 
(1)  the  infra- orbital,  corresponding  to  the  emergence  of  the  nerve  of 
that  name  from  its  bony  canal ;  (2)  the  malar,  on  the  most  prominent 


138  DISEASES    OF    THE    NERVES. 

portion  of  the  malar  bone;  (3)  a  vague  and  indeterminate  focus,  some- 
where on  the  line  of  the  gums  of  the  upper  jaw ;  (4)  the  superior 
labial  point,  a  vague  and  not  often  an  important  focus;  (5)  the  pala- 
tine point,  rarely  observed,  but  in  some  recorded  cases  the  seat  of  in- 
tolerable pain. 

In  the  inferior  maxillary  division  the  foci  are :  (1)  the  temporal,  a 
point  on  the  auriculo-teinporal  branch,  a  little  in  front  of  the  ear;  (2) 
the  inferior  dental  point,  opposite  the  emergence  of  the  nerve  of  that 
name ;  (3)  the  lingual  point  (not  a  common  one)  on  the  side  of  the 
tongue;  (4)  an  inferior  labial  point,  only  rarely  met  with. 

Besides  these  foci  in  relation  with  distinct  branches  of  the  trigemi- 
nus  there  is  one  of  especial  frequency,  which  corresponds  to  the  inos- 
culation of  various  branches.  This  is  the  parietal  point,  situated  a  little 
above  the  parietal  eminence.  It  is  small  in  size,  the  point  of  the  little 
ringer  would  cover  it.  It  is  the  commonest  focus  of  all. 

Neuralgia  of  the  fifth  may  attack  any  one,  or  all  three  of  the  divi- 
sions ;  the  latter  event  is  comparatively  rare.1  The  most  common  is 
the  case  of  its  limitation  to  the  ophthalmic  division,  and  incomparably 
the  most  frequent  foci  of  the  puiu  are  the  supra-orbital  and  parietal 
points. 

The  most  common  of  all  the  varieties  of  trigeminal  Neuralgia  is 
Migraine,  or  sick-headache.  This  is  an  affection  which  is  entirely 
independent  of  digestive  disturbances,  in  its  primary  origin,  though  it 
may  be  aggravated  by  their  occurrence.  It  almost  always  first  attacks 
individuals  at  some  time  during  the  period  of  bodily  development. 
Under  the  influences  proper  to  this  vital  epoch,  and  often  of  a  further 
debility  induced  by  precocious  straining  of  the  mental  powers,  the 
patient  begins  to  suffer  headache  after  any  unusual  fatigue  or  excite- 
ment, sometimes  without  any  distinct  cause  of  this  kind.  The  uni- 
lateral character  of  this  pain  is  not  always  detected  at  first;  but  as 
the  attacks  increase  in  frequency  and  severity,  it  becomes  obvious  that 
the  pain  is  limited  to  the  supra-orbital,  and  sometimes  to  the  ocular 
branches  of  the  ophthalmic  division  of  the  fifth  nerve  of  one  side.  In 
very  rare  cases,  however,  as  in  all  forms  of  Neuralgia,  the  nerves  of 
both  sides  may  be  affected.  If  the  pain  lasts  for  any  considerable 
time,  nausea,  and  at  length  vomiting,  are  induced.  This  is  followed 
at  the  moment  by  the  increase  of  the  severity  of  the  pain  ;  but  from 
this  point  the  violence  of  the  affection  begins  to  subside,  and  the 
patient  usually  falls  asleep.  The  history  of  the  attacks  negatives  the 
idea  that  the  vomiting  is  ordinarily  remedial.  This  symptom  merely 
indicates  the  lowest  point  of  nervous  depression ;  but  it  may  happen 
that  a  quantity  of  food  which  has  been  incautiously  taken,  lying  as  it 
does,  undigested  in  the  stomach,  may  of  itself  greatly  aggravate  the 
Neuralgia,  by  irritation  transmitted  to  the  medulla  oblongata.  In 
such  a  case  vomiting  may  directly  relieve  the  nerve-pain.  When  the 
patient  awakes  from  sleep,  the  active  pain  is  gone.  But  it  is  a  com- 

1  It  is  with  much  diffidence  that  I  make  this  statement,  as  it  is  opposed  to  the 
opinion  of  Valleix.  But  uiy  own  experience  is  very  positive  on  the  matter ;  and, 
besides,  it  appears  to  me  that  Valleix's  definition  of  Neuralgia,  which  I  cannot  ac- 
cept as  sufficiently  expansive,  accounts  for  his  views. 


NEURALGIA.  139 

mon  occurrence,  indeed  it  always  happens  when  the  Neuralgia  has 
lasted  a  certain  length  of  time,  that  a  tender  condition  of  the  super- 
ficial parts  remains  for  some  hours,  perhaps  for  a  day  or  two.  This 
tenderness  is  usually  somewhat  diffused,  and  not  limited  with  accuracy 
to  the  foci  of  greatest  pain  during  the  attacks. 

Sick-headache  is  not  uncommonly  ushered  in  by  sighing,  yawning, 
and  shuddering — symptoms  which  remind  us  of  the  prodromata  of  some 
graver  neuroses,  to  which  it  is  probably  related  by  hereditary  descent. 

Another  variety  of  trigeminal  Neuralgia  which  infests  the  period  of 
bodily  development  is  that  known  as  clavus  hystericus ;  clavus  from 
the  fact  that  the  pain  is  at  once  severe,  and  limited  to  one  or  two 
small  definite  points,  as  if  a  nail  or  nails  had  been  driven  into  the 
skull.  These  points  correspond  either  to  the  supra-orbital  or  the  parie- 
tal, sometimes  both  these  are  the  seat  of  the  pain.  But  for  the  greater 
limitation  of  the  painful  area  in  clavus,  that  affection  would  scarcely 
differ  from  migraine,  for  the  former  is  also  accompanied,  when  the  pain 
continues  long  enough,  with  nausea  and  vomiting.  The  adjective 
hystericus  is  an  improper  and  inadequate  definition  of  the  circumstances 
under  which  clavus  arises.  The  truth  is  that  the  subjects  of  it  are 
usually  females  who  are  passing  through  the  trying  period  of  bodily 
development ;  but  there  is  no  evidence  to  show  that  uterine  disorders 
give  any  special  bias  towards  this  complaint.  Both  migraine  and 
clavus  are  often  met  with  in  persons  who  have  long  passed  the  period 
of  bodily  development.  But  their  first  attacks  have  nearly  always  oc- 
curred during  that  period  of  life. 

The  adult  or  middle  period  of  life  is  not,  according  to  my  experience, 
fruitful  \nfirst  attacks  of  trigeminal  Neuralgia.  But  when  the  neural- 
gic tendency  has  once  been  set  up,  there  are  many  circumstances  of 
rniddle-adult  life  which  tend  to  recall  it.  Over-exertion  of  the  mind 
is  one  of  the  most  frequent;  more  especially  when  this  is  accompanied 
by  anxiety  and  worry ;  indeed  the  latter  is  a  more  powerful  cause 
than  the  former.  In  women,  the  exhaustion  of  hemorrhage  at  partu- 
rition, or  of  rnenorrhagia,  and  also  the  depression  produced  by  over- 
lactation,  are  frequent  causes  of  the  recurrence  of  a  migraine  or  a  clavus 
to  which  they  had  been  -subject  when  young.  The  middle  period  of 
life  is  also  most  obnoxious,  on  the  whole,  to  severe  mental  shocks,  and 
also  to  severe  bodily  accident,  of  a  kind  to  produce  damage  to  the 
central  nervous  system.  Special  mention  ought  to  be  made  in  the  case 
of  women,  of  the  disturbing  influences  of  the  great  series  of  changes 
which  close  the  middle  period  of  their  life — viz.,  the  involution  of  the 
sexual  organs.  This  is  doubtless  a  very  frequent  cause  of  the  resusci- 
tation of  a  tendency  to  facial  Neuralgia  which  had  lain  dormant,  per- 
haps, for  many  years. 

It  is,  however,  the  final,  or  degenerative  period  of  life,  which  produces 
the  most  formidable  varieties  of  facial  Neuralgia.  Neuralgias  of  the 
fifth  which  have  previously  attacked  an  individual,  may  recur  at  this 
time  of  life  without  any  special  character  except  a  certain  increase  of 
severity  and  obstinacy.  But  trigeminal  Neuralgias  which  now  occur 
for  the  first  time  are  usually  intensely  severe  and  utterly  incurable. 
These  cases  correspond  with  the  affection  named  by  Trousseau,  "tic 


140  DISEASES    OF    THE    NERVES. 

epileptiforme,"  and  it  is  of  them,  doubtless,  that  Romberg  is  speaking, 
when  he  says  that  the  true  Neuralgias  of  the  fifth  rarely  occur  before 
the  fortieth  year  of  life.  These  affections  are  distinguished  by  the  in- 
tense severity  of  the  pain,  the  lightning-like  suddenness  of  its  onset, 
and  the  almost  total  impossibility  of  effecting  more  than  the  most 
temporary  improvement  in  the  symptoms.  But  they  are  also  distin- 
guished by  another  circumstance  which  too  often  escapes  attention; 
namely,  they  are  almost  invariably  connected  with  a  family  taint  of 
insanity,  and  very  often  with  strong  melancholy  and  suicidal  tenden- 
cies in  the  patient  himself,  which  do  not  depend  on,  nor  are  commen- 
surate in  their  development  with,  the  intensity  of  the  pain  which  he 
suffers.  They  are  further  remarkable  for  the  frequency  with  which 
they  are  attended  with  two  special  complications — viz.,  muscular 
spasms,  and  the  formation  of  exquisitely  tender  points,  the  least  pres- 
sure on  which  is  enough  to  cause  the  most  violent  agony.  Often,  a 
mere  breath  of  wind  impinging  on  them  will  produce  a  like  effect. 
The  history  of  these  cases  is  most  wretched ;  the  unfortunate  patient 
may  survive  for  years  before  he  completely  succumbs  to  exhaustion ; 
yet  every  hour  of  his  life  is  a  misery.  The  act  of  masticating  usually 
causes  intolerable  darts  of  agony,  and  nutrition  is  often  obliged  to  be 
kept  up  by  liquids.  If  mere  broth  and  slop  diet  be  adhered  to,  there 
is  probably  under-nutrition  which  aggravates  the  Neuralgia.  And  if, 
as  often  happens,  the  patient  flies  to  drink  as  a  relief,  that  again  hastens 
the  degeneration  of  the  nervous  centres,  and  renders  the  case  more 
hopeless  of  cure  than  ever. 

(b)  Cervico-occipital  Neuralgia. — As  Valleix  has  remarked,  there  are 
several  nerves  (in  fact  the  posterior  branches  of  all  the  first  four 
spinal  pairs)  which  are  more  or  less  capable  of  being  the  seat  of  this 
affection.  But  amongst  them  all  there  is  none  comparable  to  the  great 
occipital,  which  arises  from  the  second  spinal  pair,  for  the  frequency 
and  importance  of  its  Neuralgic  affections.  This  nerve  sends  branches 
to  the  whole  occipital  and  the  posterior  parietal  region.  On  the  other 
hand,  the  second  and  third  spinal  nerves  help  to  make  up  the  super- 
ficial cervical  branch  of  the  cervical  plexus,  which  is  distributed  to 
the  triangle  between  the  jaw,  the  median  lines  of  the  neck,  and  the 
edge  of  the  sterno-mastoid,  and  those  to  the  lower  part  of  the  cheek. 
Then  there  is  the  auricular  branch,  which  starts  from  the  same  two 
pairs,  and  supplies  the  face,  the  parotid  region,  and  the  back  of  the 
external  ear.  Then,  the  small  occipital,  distributed  to  the  ear  and  to 
the  occiput.  And  finally  there  are  the  superficial  descending  branches 
of  the  plexus.  These,  altogether,  are  the  nerves  which  at  various 
points,  where  they  become  more  superficial,  form  the  foci  of  cervico- 
occipital  Neuralgia. 

The  most  typical  example  of  this  form  of  Neuralgia  which  has  fallen 
under  my  own  notice,  occurred  (after  exposure  to  cold  wind)  in  a  lady 
about  sixty  years  of  age,  who  had  all  her  life  been  subject  to  Neuralgic 
headache,  approaching  the  type  of  migraine,  arid  who  came  of  a  family 
in  which  insanity,  apoplexy,  and  other  grave  neuroses  had  been  fre- 
quent. The  pain  centred  very  decidedly  in  a  focus  corresponding 
to  the  occipital  triangle  of  the  neck.  It  recurred  at  irregular  inter- 


NEURALGIA.  141 

vals,  and  in  very  severe  paroxysms,  and  was  entirely  unaffected  by 
any*remedies,  till  blistering  was  tried,  when  it  yielded  at  once.  About 
twelve  months  later  this  patient  suffered  a  severe  hemiplegic  attack 
of  paralysis. 

The  tendency,  however,  of  cervico-occipital  Neuralgias  is  certainly 
to  spread  towards  the  lower  portions  of  the  face,  as  observed  by  Val- 
leix ;  in  this  case  they  become,  sometimes,  undistinguishable  from 
Neuralgias  of  the  third  branch  of  the  fifth.  In  the  early  stages  of  the 
disease,  if  the  physician  had  been  lucky  enough  to  witness  them,  the 
true  place  of  origin  of  the  malady  would  have  been  easily  discernible; 
at  a  later  date  it  requires  great  care,  and  a  very  strict  interrogation 
of  the  patient,  to  discover  the  true  history  of  the  disease. 

Experience  is  too  limited,  jf  I  am  to  judge  by  my  own  and  that  of 
the  standard  authors,  to  allow  us  to  say  anything  of  the  conditions,  . 
as  to  age  and  general  nutrition  of  the  organism  which,  specially 
favour  cervico-occipital  Neuralgia.  Apparently,  however,  there  is 
good  reason  for  thinking  that  the  immediately  exciting  cause  of  it  is 
most  frequently  external  cold.  And  I  am  inclined  to  think  also  that 
it  is  seldom  a  primary  Neuralgia,  but  occurs  usually  in  subjects  who 
have  already  experienced  other  forms. 

(c)  Cervico-brachial  Neuralgia. — This  class  includes  all  the  Neural- 
gias which  occur  in  nerves  originating  from  the  brachial  plexus,  as 
from  the  posterior  branches  of  the  four  lower  cervical  nerves.  The 
most  important  characteristic  of  the  Neuralgias  of  the  upper  extremity 
is  the  frequency,  indeed  almost  constancy,  with  which  they  invade 
simultaneously  or  successively  several  of  the  nerves  which  are  de- 
rived from  the  lower  cervical  pairs.  The  neuralgic  affections  of  the 
small  posterior  branches  (distributed  to  the  skin  of  the  lower  and 
back  part  of  the  neck)  are  comparatively  of  slight  importance.  But 
the  "  solidarite,"  which  Yalleix  so  well  remarked,  between  the  various 
branches  of  the  brachial  plexus,  causes  the  Neuralgias  of  the  shoulder, 
the  arm,  forearm,  and  hand  to  be  extremely  troublesome  and  severe, 
owing  to  the  numerous  foci  of  pain  which  usually  exist.  Perhaps 
Valleix's  description  of  these  foci  is  somewhat  fanciful  and  over-mi- 
nute; but  the  following  among  these  which  he  mentions  I  have  re- 
peatedly identified  :  (l)an  axillary  point,  corresponding  to  the  brachial 
plexus  itself;  (2)  a  scapular  point,  corresponding  to  the  inferior  angle 
of  the  scapula.  (It  is  difficult  to  identify  the  peccant  nerve  here  :  the 
one  to  which  it  apparently  corresponds,  and  to  which  Valleix  refers 
it,  is  the  sub-scapular;  but  we  are  accustomed  to  think  of  this  as  a 
motor  nerve).  Still  it  is  certain  that  pressure  on  a  painful  point  ex- 
isting here  will  often  cause  acute  pain  in  the  nerves  of  the  arm  and 
forearm.  (3)  A  shoulder  point,  which  corresponds  to  the  emergence, 
through  the  deltoid  muscle,  of  the  superficial  filets  of  the  circumflex; 
(4:)  a  median-cephalic  point,  at  the  bend  of  the  elbow,  where  a  branch  of 
the  musculo-cutaneous  nerve  lies  immediately  behind  the  median 
cephalic  vein  ;  (5)  an  external  humeral  point,  about  three  inches  above 
the  elbow,  on  the  outer  side,  corresponding  to  the  emergence  of  the 
cutaneous  branches  which  the  musculo-spiral  gives  off  as  it  leaves  the 
groove  in  the  humerus;  (6)  a  superior  ulnar  point,  corresponding  to 


142  DISEASES    OF    THE    NERVES. 

the  course  of  the  ulnar  nerve,  between  the  olecranon  and  the  epi-tro- 
chlea ;  (7)  an  inferior  ulnar  point,  where  the  nerve  passes  in  front  of 
the  annular  ligament  of  the  wrist;  (8)  a  radial  point,  making  the 
place  where  the  radial  nerve  becomes  superficial  at  the  lower  and  ex- 
ternal aspect  of  the  forearm.  Besides  these  foci,  there  are  sometimes, 
but  more  rarely,  painful  points  developed  by  the  side  of  the  lower 
cervical  vertebrae,  corresponding  to  the  posterior  branches  of  the  lower 
cervical  pairs. 

The  most  common  seat  of  brachial  Neuralgia  in  my  experience  has 
been  the  ulnar  nerve ;  the  superior  and  inferior  points  above  men- 
tioned being  the  foci  of  greatest  intensity  ;  an  axillary  point  has  also 
been  developed  in  one  or  two  instances  which  I  have  seen.  Rarely, 
however,  does  the  Neuralgia  remain  limited  to  the  ulnar  nerve,  in  the 
majority  of  cases  it  soon  spreads  to  other  nerves  which  emanate  from 
the  plexus.  A  very  common  seat  of  Neuralgia  is  also  the  shoulder, 
the  affected  nerves  being  the  cutaneous  branches  of  the  circumflex. 
I  am  inclined  to  think,  also,  that  affections  of  the  musculo-spiral  and 
of  the  radial  near  the  wrist  are  rather  common,  and  have  found  them 
extremely  obstinate  and  difficult  to  deal  with.  One  case  has  recently 
been  under  my  care  in  which  the  foci  of  greatest  intensity  of  pain 
were  an  external  humeral,  and  a  radial  point ;  but  besides  this  there 
was  an  exquisitely  painful  scapular  point.  In  another  instance,  the 
pain  commenced  in  an  external  humeral  and  a  radial  focus ;  but 
subsequently  the  shoulder  branches  of  the  circumflex  became  involved. 
A  most  plentiful  crop  of  herpes  was  an  intercurrent  phenomenon  in 
this  case. 

Median  cephalic  Neuralgia  is  an  affection  which  used  to  be  com- 
paratively common  in  the  days  when  phlebotomy  was  in  fashion,  the 
nerve  being  occasionally  wounded  in  the  operation.  I  have  only  seen 
it  in  connection  with  this  cause;  that  is  to  say,  as  a  well-marked 
affection.  One  such  instance  has  been  under  my  care.  But  a  slight 
degree  of  it  is  not  uncommon,  as  a  secondary  symptom  in  Neuralgia 
affecting  other  nerves.  The  traumatic  form  is  excessively  obstinate. 

In  the  Neuralgias  of  the  arm  we  begin  to  recognize  the  etiological 
characteristic  which  distinguishes  most  of  the  neuralgic  affections  of 
limbs,  namely,  the  frequency  with  which  they  are  aggravated,  and 
especially  with  which  they  are  kept  up  and  revived,  when  apparently 
d}7ing  out,  by  muscular  movements.  In  the  case  above  referred  to  of 
Neuralgia  of  the  sub-scapular,  musculo-spiral  (cutaneous  branches),  and 
radial,  the  act  of  playing  on  the  piano  for  half  an  hour  immediately 
revived  the  pains  in  fullest  force,  when  convalescence  had  apparently 
been  almost  established. 

The  liability  of  particular  nerves  in  the  upper  extremity  to  Neuralgia, 
from  external  injuries,  requires  a  few  words.  The  nerve  which  is  pro- 
bably most  exposed  to  this  is  the  ulnar.  Blows  on  what  is  vulgarly 
called  the  funny  bone  are  not  uncommon  exciting  causes  of  the  affection 
in  predisposed  persons:  and  cutting  wounds  of  the  ulnar  a  little  above 
the  wrist  are  rather  frequent  causes.  The  deltoid  branches  of  the  cir- 
cumflex, and  the  humeral  cutaneous  branches  of  the  musculo-spiral, 
are  much  exposed  to  injury.  The  radial  nerve  near  the  wrist  is  very 


NEURALGIA.  143 

much  exposed  both  to  bruises  and  to  cutting  wounds.  So  far  as  T 
know  it  is  only  when  a  nerve-trunk  of  some  size  is  injured  that 
Neuralgia  is  a  probable  result.  Wounds  of  the  small  nervous  branches 
in  the  fingers,  for  instance,  are  very  seldom  followed  by  Neuralgia. 
I  have  no  statistics  to  guide  me  as  to  the  effect  of  long-continued  irri- 
tation applied  to  one  of  those  small  peripheral  branches;  but  it  is  pro- 
bable that  that  might  be  more  capable  of  inducing  Neuralgia.  As 
far  as  my  own  experience  goes,  however,  it  would  appear  that  a  more 
common  result  is  convulsion  of  some  kind,  from  reflex  irritation  of  the 
cord. 

(d)  Dorso- Intercostal  Neuralgia. — This  form  of  Neuralgia  has  of  late 
years  assumed  a  position  of  much  interest,  in  consequence,  chiefly,  of 
its  rather  frequent  association  with  unilateral  herpes,  a  circumstance 
which  has  considerably  helped  to  elucidate  the  pathology  of  the  latter 
disease. 

This  disease  is  surrounded  with  considerable  diagnostic  difficulties. 
Some  of  these  will  be  discussed  under  the  heading  of  Diagnosis  in  part ; 
but  a  few  words  must  be  given  to  them  here.  The  disorder  with 
which  it  is  especially  liable  to  be  confounded  is  that  for  which  Dr. 
Jnman  invented  the  term  Myalgia,  and  which  is  represented  in  different 
localities  by  the  affections  called  in  old-fashioned  phrase  pleuro-dynia, 
lumbago,  and  (more  generally)  by  the  very  inaccurate  term  muscular 
rheumatism  (there  being  no  respectable  evidence  whatever  to  connect 
it  specially  with  the  rheumatic  diathesis).  The  principal  feature  by 
which  dorso-intercostal  Neuralgia  can  be  separated  from  myalgia  is 
its  history;  viz.,  its  non-dependence,  or  much  less  dependence  on  ex- 
cessive or  long-continued  local  muscular  action  than  the  latter  complaint 
exhibits.  There  is  also  a  marked  intermittence  in  the  neuralgic  affec- 
tions. Finally,  though  this  only  applies  to  a  limited  number  of  cases, 
the  intercurrence  of  herpes  is  a  decided  diagnostic  of  the  neuralgic 
character  of  the  disease. 

Dorso-intercostal  Neuralgia  is  an  affection  of  certain  of  the  dorsal 
nerves.  These  nerves  divide  immediately  after  their  emergence  from 
the  intervertebral  foramina  into  a  posterior  and  an  anterior  branch. 
The  former  sends  filaments  which  pierce  the  muscles,  to  be  distributed 
to  the  skin  of  the  back;  the  latter,  forming  the  intercostal  nerves, 
follow  the  intercostal  spaces.  Immediately  after  their  commencement 
the  intercostal  nerves  communicate  with  the  corresponding  ganglia  of 
the  sympathetic.  Proceeding  outwards  they  at  first  lie  between  the 
pleura  and  intercostal  muscles;  towards  the  angles  of  the  ribs  they 
pass  between  the  two  layers  of  intercostal  muscles,  and,  after  giving 
branches  to  the  latter,  give  oft'  their  large  superficial  branch.  In  the 
case  of  the  seventh,  eighth,  or  ninth  intercostal  nerves,  which  are 
those  chiefly  liable  to  Neuralgia,  the  superficial  branch  is  given  off 
about  midway  between  the  spine  and  sternum.  The  final  point  of 
division,  at  which  superficial  filets  come  off,  in  all  the  eight  lower 
intercostal  nerves,  is  nearer  to  the  sternum,  and  is  progressively  nearer 
to  the  latter  in  each  successive  space  downwards.  There  are  thus,  as 
Yalleix  observes,  three  points  of  division :  1,  at  the  inter-vertebral 
foramen  ;  2,  midway  in  the  intercostal  space ;  3,  near  to  the  sternum. 


144  DISEASES    OF    THE    NERVES. 

Arid  there  are  three  sets  of  superficial  branches  (reckoning  the  posterior 
primary  division)  which  make  their  way  towards  the  surface  near 
these  points. 

In  one  of  its  forms,  intercostal  Neuralgia  is  one  of  the  commonest 
of  all  neuralgic  affections.  I  refer  to  the  pain  beneath  the  left  mamma, 
which  women  with  neuralgic  tendencies  so  often  experience,  chiefly  in 
consequence  of  over-lactation,  but  also  from  exhaustion  caused  by 
menorrhagia,  and  especially  from  the  concurrence  of  this  cause  with 
the  preceding  one.  Some  care  must  be  taken  to  distinguish  this  from 
the  mere  myalgic  pain,  which  is  produced  by  over-working  the  pectoral 
muscles  in  proportion  to  the  existing  state  of  their  nutrition,  and  also 
by  the  vague  conditions  grouped  under  the  name  "Hysteria."  The 
latter  sort  of  pain  is  more  diffuse  in  extent,  and  less  markedly  inter- 
mittent, than  Neuralgia,  and  its  history  is  different :  and  the  effect  of 
rest  is  far  more  marked  in  the  former  than  in  the  latter. 

It  is  only  of  recent  years  that  the  Neuralgia  which  had  often  been 
observed  to  attend  herpes  zoster  has  been  even  thought  of  as  essen- 
tially connected  with  the  latter  disease.  It  is  to  M.  Notta  that  some 
of  the  earliest  observations  leading  to  the  latter  view  are  to  be  attri- 
buted. But  the  matter  was  much  more  fully  discussed  by  M.  Baren- 
sprung,  in  a  paper  published  in  1861.1  This  author  showed  the 
absolute  universality  with  which  unilateral  herpes,  wherever  developed, 
closely  followed  the  distribution  of  some  superficial  sensory  nerve, 
and  gave  reasons,  which  will  be  discussed  hereafter,  for  supposing  that 
the  disease  originates  in  the  ganglia  of  the  posterior  roots,  and  that 
the  irritation  spread  thence  to  the  posterior  roots  in  the  cord,  causing 
reflex  Neuralgia.  This  theory  will  be  discussed  further.  Meantime, 
it  seems  to  be  established,  by  multiplied  researches,  that  though  uni- 
lateral herpes  may,  and  often  does,  occur  without  neuralgia  and  neu- 
ralgia without  herpes,  the  concurrence  of  the  two  is  due  to  a  mere 
extension  of  the  original  disease,  which  is  a  nervous  one. 

In  young  persons  zoster  is  not  often  attended  with  severe  Neuralgia, 
but  a  curious  half-paretic  state  of  the  skin,  in  which  numbness  is 
mixed  with  formication,  or  with  a  sensation  as  of  boiling  water  under 
the  skin,  precedes  the  outbreak  of  the  eruption  by  some  hours,  or  even 
a  day  or  two.  Painless  herpes  is  commonest  in  youth.  From  the  age 
of  puberty  to  the  end  of  life  the  tendency  of  herpes  to  be  complicated 
with  Neuralgia  becomes  progressively  stronger.  The  course  of  events 
is  different  in  different  cases,  however.  Usually,  in  adult  and  later  life, 
the  symptoms  commence  with  a  more  or  less  violent  attack  of  neuralgic 
pain,  which  is  succeeded,  and  for  the  time  usually  (though  not  always) 
displaced,  by  the  herpetic  eruption.  This  latter  runs  its  course,  and 
after  its  disappearance  the  Neuralgia  very  commonly  returns  again. 
In  old  people  the  a/ter-Neuralgia  is  often  distressingly  severe,  and 
most  rebellious  to  treatment.  Six  weeks  or  two  months  is  quite  a 
common  period  for  it  to  last,  and  in  some  aged  persons  it  has  been 
known  to  fix  itself  permanently,  and  cease  only  with  life.  In  elderly 

1  Amialen  der  Cliarite  Krankeuliauses  ziir  Berliu,  ix.  2,  p  40.  Brit,  aud  For.  Med. 
Rev.,  January,  1862. 


NEURALGIA.  145 

subjects  a  further  complication  sometimes  occurs.  The  herpetic  vesi- 
cles leave  obstinate  and  most  painful  ulcers  behind  them,  which  refuse 
to  heal,  and  worry  the  patient  frightfully,  the  merest  breath  of  air 
upon  them  sufficing  to  cause  agonizing  darts  of  neuralgic  pain.  I 
have  known  one  patient  distinctly  killed  by  the  exhausting  agony 
thus  caused. 

The  foci  of  pain  in  intercostal  Neuralgia  are  always  found  in  one  or 
more  of  the  points,  already  mentioned,  at  which  sensory  twigs  become 
superficial.  In  long-standing  cases  acutely  tender  spots  are  developed  ; 
not  unfrequeritly  the  most  decided  of  these  are  where  they  are  too 
seldom  sought  for,  namely,  opposite  the  emergence  from  the  inter- 
vertebral  foramen. 

(e)  Dorso-lumbar  Neuralgia. — The  records  of  this  affection  are  as 
yet  in  a  state  of  considerable  confusion.     What  has  been  done  with 
any  precision  towards  clearing  up  the  history  of  the  disease,  related 
chiefly  to  the  neuralgic  affections  of  the  pelvic  organs  in  women  ;  and 
to  the  Neuralgia  of  the  testis  in  men,  which  will  be  treated  of  in  a 
different  place. 

The  principal  foci  of  dorso-lumbar  Neuralgia,  when  this  affects  ex- 
ternal parts,  are  as  following:  (1)  the  vertebral  points,  corresponding 
to  the  posterior  branches  of  the  respective  nerves;  (2)  an  iliac  about 
the  middle  of  the  crista  ilii ;  (3)  an  abdominal  point,  in  the  hypogastric 
region ;  (4)  an  inguinal  point  in  the  groin  near  the  issue  of  the  sper- 
matic cord,  from  whence  the  pain  radiates  along  the  latter;  (5)  a 
scrotal  or  labial  point,  situated  in  the  scrotum,  or  in  the  labiurn  majus. 

Such  is  the  description  given  by  Valleix;  and  as  I  have  seen  but 
few  examples  of  the  external  forms  of  dorso-lumbar  Neuralgia  I  can 
only  rely  upon  his  observation.  The  few  severe  cases  of  this  kind  of 
Neuralgia,  which  I  have  observed,  have  been  distinguished  by  foci  in 
the  vertebral  region,  and  over  the  crista  ilii;  in  two  of  these  there 
were  also  distinct  foci  in  the  spermatic  cord  and  testicle.  In  one 
patient  there  was  an  apparent  focus  of  pain  higher  up  in  the  groin 
also;  but  this  man  is  a  confirmed  hypochondriac,  and  his  morbid 
sensations  are  so  shifting  as  to  be  very  unreliable  in  their  indications. 

(f)  The  next  group  of  Neuralgias  which  must  be  described  is  the 
crural.     This,  after  all,  includes  very  few  independent  cases.     There 
are  very  few  primary  Neuralgias  of  the  crural  nerve ;  Valleix  had  only 
seen  two  in  his  very  large  experience,  and  I  cannot  say  that  I  have 
seen  any.     Neuralgia  of  the  crural  nerve  is  almost  always  a  secondary 
affection,  arising  in  the  course  of  .Neuralgia,  which  primarily  showed 
itself  in  the  external  pudic  branch  from  the  plexus. 

(g)  The  last,  and  one  of  the  most  important  and  numerous  groups 
of  external  Neuralgias  are  the  femoro-popliteal,  or  Sciatic. 

Sciatica  is  a  disease  from  which  youth  is  comparatively  exempt. 
Valleix  had  collected  124  cases ;  and  in  not  one  was  the  patient  below 
the  age  of  seventeen  ;  only  4  were  below  twenty.  In  the  next  decade 
there  were  22;  in  the  next  30;  and  the  largest  number  of  cases,  35, 
were  between  the  ages  of  forty  and  fifty.  This  completely  tallies  with 
my  own  experience;  and  seems  to  favour  the  suspicion  which  I  have 
formed,  that  the  pressure  exerted  on  the  nerve  in  locomotion  and  in 
10 


14:6  DISEASES    OF   THE    NERVES. 

sitting  is  one  principal  cause  of  the  great  liability  to  Neuralgia  which 
distinguishes  the  sciatic  nerve;  and  this  idea  seerns  to  be  favoured  by 
the  further  fact  elicited  by  Valleix,  that  from  thirty  years  onward  the 
number  of  male  is  greatly  higher  than  that  of  female  sciatic  patients. 

There  are  three  very  distinct  varieties  of  the  disease,  however, 
according  to  my  experience.  The  first  variety  is  obscure  in  its  origin, 
but  may  be  said,  in  general  terms,  to  be  connected  with  a  strongly 
marked  nervous  temperament,  which  is  indicated  in  the  female  by  a 
tendency  to  hysteria,  and  in  the  male  by  an  abnormal  sensibility  to 
nervous  impressions.  The  subjects  of  this  variety  of  sciatica  are 
mostly  below  the  age  of  forty,  and  have  generally  been  liable  to  other 
forms  of  Neuralgia;  the  actual  attack  of  sciatica  is  excited  by  some 
bodily  fatigue  or  mental  distress  which,  on  other  occasions,  has  pro- 
duced sick-headache,  or  intercostal  Neuralgia,  &c.  Very  many  of  these 
patients  are  anaBmic.  The  greater  number  of  them  are  females,  and  in 
many  (whether  as  cause  or  effect)  there  is  decided  amenorrhcea,  and 
sometimes  chlorosis.  In  this  variety  the  pain,  though  chiefly  affect- 
ing the  sciatic  nerve  and  its  branches,  is  apt  secondarily  to  invade 
some  of  the  nerves  which  issue  from  the  lumbar  plexus.  I  cannot 
avoid  the  suspicion,  though  the  proof  is  most  difficult,  that  the  affec- 
tion not  unfrequently  depends  on,  or  is  much  aggravated  by,  an 
excited  condition  of  the  sexual  apparatus  :  certainly  I  have  observed 
it  with  marked  frequency  in  women  who  remain  single  long  after  the 
marriageable  age,  and  in  the  case  of  several  male  patients  there  has 
been  either  the  certainty  or  a  strong  suspicion  of  venereal  excess. 
The  actual  outbreak  of  pain  is  generally  sudden,  but  in  many  instances 
there  has  been  a  tendency  to  numbness,  or  abnormal  sensations,  in  the 
skin  of  the  back  part  of  the  thigh,  or  in  some  part  of  the  course  of  the 
branches  of  the  nerve  for  some  time  previously.  Like  all  forms  of 
sciatica,  this  affection  is  usually  obstinate,  and  requires  assiduous  and 
sometimes  prolonged  treatment  for  its  removal ;  but  it  is  incomparably 
more  manageable  than  other  varieties. 

The  second  variety  of  sciatica  occurs  for  the  most  part  in  middle 
aged  or  old  persons  who  have  long  been  subject  to  excessive  muscular 
exertion,  or  have  been  much  exposed  to  cold,  and  especially  damp 
cold,  or  who  have  been  subjected  to  both  of  these  kind  of  evil  influences. 
One  must  include  also,  I  think,  in  this  group,  a  certain  number  of 
patients  whose  age  need  not  be  so  advanced,  but  who  have  been 
liable,  along  with  depressing  influences  of  a  constitutional  kind,  to 
prolonged  pressure  on  the  nerve  from  the  habitual  maintenance  of  the 
sitting  posture,  in  their  business,  for  many  hours  together. 

The  patients  who  suffer  from  this  second  variety  of  sciatica  are 
mostly,  as  already  said,  of  middle  age  or  more ;  but  this  statement 
must  be  understood  to  be  made  in  the  comparative  sense  which  refers 
rather  to  the  vital  condition  of  the  individual  than  to  the  mere  lapse 
of  years.  Many  of  them  have  hair  which  is  prematurely  gray  :  and 
in  some  the  existence  of  rigid  arteries,  together  with  arcus  senilis, 
completes  the  picture  of  organic  degeneration.  In  particular  cases 
where  depressing  influences  have  been  at  work  for  a  long  time,  or 
unusually  active,  these  appearances  rectify  the  impression  we  should 


NEURALGIA.  147 

otherwise  receive  from  learning  the  nominal  age  of  an  individual; 
this  is  especially  the  case  with  persons  who  have  for  a  long  time  drunk 
to  excess.  I  am  at  a  loss  to  know  how  Yalleix  and  many  others  can 
have  overlooked  the  frequent  occurrence  of  this  type  of  constitution 
among  the  most  numerous  group  of  sciatic  patients — those  between 
thirty  and  fifty  years  of  age  :  unless,  indeed,  we  suppose  that  many  of 
their  "  robust"  patients  were  so  fresh  in  colour  and  possessed  such 
good  muscular  strength  as  to  lead  the  physician  to  ignore  the  far  more 
significant  indications  which  are  given  by  the  above-mentioned 
appearances. 

A  prominent  feature  in  this  variety  of  sciatica  is  its  great  obstinacy 
and  intractability.  Another  equally  marked  is  the  development, 
around  one  or  more  foci  of  severest  pain,  of  spots  which  are  perma- 
nently and  intensely  tender,  and  the  slightest  pressure  on  which  is 
sufficient  to  renew  the  agony  of  acute  pain:  this  development  of 
tender  points  is  far  less  marked  in  the  preceding  form  of  the  disease. 
The  places  which  are  specially  apt  to  present  this  phenomenon  are  as 
follows:  (1)  A  series  or  line  of  points,  representing  the  cutaneous 
emergence  of  the  posterior  branches,  which  reaches  from  the  lower 
end  of  the  sacrum  up  to  the  crista  ilii.  (2)  A  point  opposite  the 
emergence  of  the  great  and  small  sciatic  nerves  from  the  pelvis,  (3) 
A  point  opposite  the  cutaneous  emergence  of  the  ascending  branches 
from  the  small  sciatic  which  run  up  towards  the  crista  ilii.  (4)  Seve- 
ral points  at  the  posterior  aspect  of  the  thigh,  corresponding  with  the 
cutaneous  emergence  of  the  filets  of  the  crural  branch.  (5)  Afibular 
point,  at  the  head  of  the  fibula,  corresponding  to  the  division  of  the 
external  popliteal.  (6)  An  external  malleolar,  behind  the  outer  ankle. 
(7)  An  internal  malleolar. 

Another  circumstance  which  distinguishes  the  form  of  sciatica 
which  we  are  considering,  is  the  degree  in  which  (above  all  other 
forms  of  Neuralgia)  it  involves  paralysis.  By  far  the  largest  part  of 
the  whole  rrcotor-nervous  supply  for  the  limbs  passes  through  the 
trunk  of  the  great  sciatic ;  it  might  therefore  be  naturally  expected 
that  a  strong  affection  of  the  sensory  portion  of  the  nerve  would,  in 
a  reflex  manner,  produce  some  powerful  effect  on  the  motor  element. 
This  effect  is  most  frequently  in  the  direction  of  paralysis.  Complete 
palsy  is  rare,  but  in  a  large  number  of  cases  which  have  lasted  some 
time  there  can  be  no 'doubt  that  there  is  a  positive  and  very  consider- 
able loss  of  motor  power,  independently  of  any  effect  which  may  be 
produced  by  wasting  of  muscles.  It  is  of  course  necessary  to  avoid 
the  fallacy  which  might  be  produced  by  neglecting  to  observe 
whether  movement  was  merely  restricted  in  consequence  of  its  pain- 
fulness. 

Anaesthesia  is  also  a  common  complication  of  sciatica,  far  commoner, 
as  I  venture  to  think,  than  it  has  been  represented  either  by  Yalleix 
or  Notta.  It  is  necessary,  however,  to  be  explicit  on  this  point.  In 
the  early  stages  both  of  this  form  of  sciatica  and  of  the  milder  varie- 
ties previously  described,  there  is  almost  always  partial  numbness  of 
the  skin  previous  to  the  first  outbreak  of  neuralgic  pain,  and  during 
the  intervals  between  the  attacks.  By  degrees  this  is  exchanged,  in 


148  DISEASES    OP    THE    ZSTERVES. 

the  milder  form,  for  a  generally  diffused  hypersesthesia  around  the 
foci  of  neuralgic  pain,  while  other  portions  of  the  limb  may  still  re- 
main anaesthetic.  In  the  severer  forms  it  sometimes  happens  that, 
besides  an  intense  hypersesthesia  of  the  skin  over  the  painful  foci, 
there  is  diffused  hypersesthesia  over  a  greater  part  or  the  whole  of 
the  surface  of  the  limb.  But  it  is  important  to  remark  that  both  in 
the  anaesthetic  and  the  hyperassthetic  conditions  (so  called),  the  tactile 
sensibility  is  very  much  diminished.  I  have  made  a  great  many  exami- 
nations of  painful  limbs  in  sciatica,  and  have  never  failed  to  find  (with 
the  compass  points)  that  the  power  of  distinctive  perception  was  very 
decidedly  lowered. 

Convulsive  movements  of  muscles  are  met  with  in  a  moderate  propor- 
tion of  the  cases  of  severe  sciatica  of  middle  and  advanced  life,  in 
which  affection  they  are  entirely  involuntary.  They  differ  from  cer- 
tain spasmodic  movements  not  unfrequently  observed  in  the  milder 
form  (and  especially  in  hysteric  women),  for  these  are  more  connected 
with  defective  volition,  and  are,  in  truth,  not  perfectly  involuntary. 
In  several  cases  of  inveterate  sciatica  I  have  seen  violent  spasmodic 
flexures  of  the  leg  upon  the  thigh.  Cramps  of  particular  muscles 
are  occasionally  met  with.  I  have  seen  the  flexors  of  all  the  toes  of 
the  affected  limb  violently  cramped  ;  and  in  one  case  the  patient  was 
troubled  with  severe  cramps  of  the  gastrocnemius.  It  is  chiefly  at 
night,  and  especially  when  the  patient  is  just  falling  asleep,  that  this 
kind  of  affection  is  apt  to  occur. 

A  third  variety  of  sciatica  is  the  rather  uncommon  one  (so  far  as 
my  experience  goes)  in  which  inflammation  of  the  tissues  around  the 
nerve  is  the  primary  affection,  and  the  Neuralgia  is  a  mere  secondary 
effect,  from  mechanical  pressure  on  the  nerve  which,  however,  is 
apparently  not  itself  inflamed.  I  believe  that  these  cases  are  some- 
times caused  by  syphilis,  and  sometimes  by  rheumatism.  It  need 
hardly  be  said  that  this  affection  is  essentially  different,  and  requires 
a  different  treatment  from  Neuralgias  in  which  the  disturbances  origi- 
nate in  the  nervous  system. 

(II.)  Visceral  Neuralgias. — This  most  important  class  of  diseases 
still  remains  very  much  unknown ;  but  it  is  constantly  assuming  a 
greater  consequence.  The  Neuralgias  of  viscera,  of  which  anything 
can  with  confidence  be  said,  are  the  following :  (1)  Cardiac,  (2)  Hepa- 
tic, (3)  Gastric,  (4)  Peri-uterine  (including  ovarian),  (5)  Testicular, 
(6)  Renal. 

It  is,  however,  unnecessary  to  describe  the  clinical  history  of  these 
disorders  here,  since  they  will  be  treated  of  under  the  headings  of  the 
morbid  affections  of  the  particular  organs  which  they  infest. 

COMPLICATIONS. — This  part  of  our  subject  is  of  the  greatest  interest, 
and  the  facts  regarding  it  are,  to  a  considerable  extent,  of  recent  dis- 
covery. If  we  turn  to  the  excellent  treatises  of  Valleix  and  Romberg, 
which  appeared  about  a  quarter  of  a  century  ago,  we  find  a  very  inade- 
quate importance  assigned  to  the  secondary  affections  which  occur  in 
Neuralgia.  The  convulsive  movements  of  the  facial  muscles  which 
occur  in  the  severer  forms  of  tic  douloureux  could  not  fail,  of  course, 
to  attract  attention  even  from  the  earlier  tim-js.  Of  the  functions  of 


NEURALGIA.  149 

special  sense  Valleix'only  mentioned  hearing  as  liable  to  be  affected. 
Injection  of  the  conjunctiva  he  spoke  of  as  if  it  were  a  rare  pheno- 
menon in  trigeminal  Neuralgia.  He  did  not  mention  modifications  of 
nutrition  at  all,  except  those  of  the  hair;  and  of  modifications  of 
secretion  he  only  enumerated  lachrymatiori,  mucous  flux  from  the 
nostril,  and  salivation  as  occasional  phenomena.  Of  disturbances  of 
the  stomach  he  took  a  more  appreciative  view ;  and  he  mentioned,  as 
a  remarkable  fact,  that  he  never  knew  facial  neuralgia  caused  by 
gastric  disturbance,  but  had  frequently  observed  the  latter  affection  to 
occur  in  the  course  of  a  neuralgic  attack,  and  apparently  as  the  conse- 
quence of  it.  He  gives  no  pathological  explanation  of  the  connection 
between  them. 

It  is  to  M.  Notta1  that  we  owe  the  first  scientific  treatment  of  this 
subject  of  the  complications  of  Neuralgia.  The  importance  of  these 
secondary  affections  is  particularly  brought  out  by  this  author  in  his 
remarks  on  trigeminal  Neuralgia,  of  which  he  analyzes  128  cases.  As 
regards  special  senses,  he  states  that  the  retina  was  completely,  or 
almost  completely,  paralyzed  in  ten  cases,  and  in  nine  others  vision 
was  interfered  with;  partly,  probably,  from  impaired  function  of  the 
retina,  but  partly,  also,  from  dilatation  of  the  pupil,  or  other  func- 
tional derangement  independent  of  the  optic  nerve.  The  sense  of 
hearing  was  impaired  in  four  cases.  The  sense  of  taste  was  perverted 
in  one  case,  and  abolished  in  another.  As  regards  secretion  :  Lachry- 
mation  was  observed  in  sixty-one  cases,  or  nearly  half  the  total 
number.  Nasal  secretion  was  repressed  in  one  case ;  in  ten  others  it 
was  increased  on  the  affected  side.  Unilateral  sweating  is  spoken  of 
more  doubtfully,  but  is  said  to  be  probably  present  in  a  considerable 
number  of  cases.  In  eight  instances  there  was  decided  unilateral  red- 
ness of  the  face,  and  five  times  this  was  attended  with  noticeable 
tumefaction.  In  one  case  the  uuiliteral  redness  and  tumefaction  per- 
sisted, and  were,  in  fact,  accompanied  by  a  general  hypertrophy  of  the 
tissues.  Dilatation,  of  the  conjunctival  vessels  was  observed  in  thirty- 
four  cases.  Nutrition  was  affected  as  follows:  In  four  cases  there 
was  unilateral  hypertrophy  of  the  tissues  ;  in  two,  the  hair  was  hyper- 
trophied  at  the  ends,  and  in  several  other  cases  it  was  observed  to  fall 
off'  or  to  turn  gray.  The  tongue  was  greatly  tumefied  in  one  case. 
Muscular  contractions,  on  the  affected  side,  were  noted  in  fifty-two 
cases;  of  these,  in  thirteen,  the  contractions  were  in  the  muscles  of 
the  lip  and  nostril ;  in  ten,  there  was  tremor  of  the  eyelid ;  in  a  great 
number  many  muscles  were  simultaneously  affected.  Permanent  tonic 
spasm  (not  due  to  photophobia)  was  observed  in  the  eyelid  in  four 
eases;  in  the  muscles  of  mastication,  four  times;  in  the  muscles  of 
the  external  ear,  once.  Paralysis  affected  the  motor  oculi,  causing 
prolapse  of  the  upper  eyelid,  in  six  cases;  in  half  of  these  there  was 
also  outward  squint.  In  two  instances  the  facial  muscles  were  para- 
lyzed in  a  purely  reflex  manner.  The  pupil  was  dilated  in  three 
cases,  and  contracted  in  two  others,  without  any  impairment  of  light ; 
iu  three  others  it  was  dilated,  with  considerable  diminution  of  visual 

1  Archives  Geuerales  de  Medeciiie,  1854. 


150  DISEASES    OF    THE    NERVES. 

power.  Finally,  with  regard  to  common  sensibility — M.  Notta  reports 
three  cases  in  which  ancesihesia  was  observed.  Hypercesthesia  of  the 
surface  only  occurred  in  the  later  stages  of  the  disease. 

Various  other  observers  have  added  to  this  list  of  the  secondary 
affections  which  may  occur  in  facial  Neuralgia  the  following  :  Iritis, 
glaucoma,  corneal  clouding,  and  even  ulceration;  periostitis,  unilateral 
furring  of  the  tongue,  herpes  unilateralis,  &c. 

All  the  above  complications  of  fascial  Neuralgia,  excepting  glau- 
coma, have  been  under  my  own  observation,  and  most  of  them  I  have 
seen  in  a  great  many  cases.  Moreover,  my  own  attention  had  been 
called  independently  to  the  subject  by  my  own  unlucky  personal  expe- 
rience. I  began,  at  the  age  of  about  fourteen,  to  suffer  from  attacks 
of  unilateral  facial  Neuralgia  in  the  right  side  (chiefly  supra-orbital), 
which  very  soon  assumed  the  type  of  severe  migraine,  such  as  it  has 
already  been  described.  A  year  or  two  later,  the  pains  being  at  this 
time  severe  and  frequent,  there  occurred  a  painful  thickening  and 
tumefaction  of  the  periosteum  round  the  brow,  arid  also  the  formation 
of  one  or  two  dense  white  patches  on  the  cornea,  in  the  centre  of 
which  small  phlyctenular  ulcers  appeared.  About  the  same  time, 
probably,  there  occurred  a  great  thickening  of  the  fibrous  tissue, 
surrounding  the  upper  end  of  the  nasal  duct,  which  caused  a  dense 
stricture  of  that  canal.  Some  years  later,  when  the  attacks  had 
become  much  less  frequent,  they  recurred  with  great  severity  during 
the  prostration  brought  on  by  choleraic  diarrhoea.  I  then  first  noticed 
that  the  hair  of  the  eyebrow  was  whitened  opposite  the  supra-orbital 
notch,  and  that  gray  hairs  were  thickly  strewn  over  the  right  side  of 
the  head  for  some  time  after  the  attack ;  and  this  phenomenon  has 
occurred  after  every  severe  attack  since  that  time.  It  only  lasts  in 
intensity  for  a  few  days,  and  the  colour  soon  becomes  partially  re- 
stored to  its  original  tint,  but  without  any  falling  off  of  the  hair.  The 
latter  fapt  seems  at  first  difficult  of  belief;  but  I  have  most  closely 
observed  the  phenomenon,  and  have  since  witnessed  the  same  thing 
in  several  patients,  both  of  my  own  and  other  practitioners.  Another 
nutritive  modification  which  I  have  seen  in  my  own  case  is  the  forma- 
tion of  a  dense  epithelial  fur  on  one  half  of  the  tongue. 

There  is  another  complication  which,  so  far  as  I  am  aware,  was  first 
identified  by  myself  as  having  a  definite  relation  to  facial  Neuralgia: 
viz.  erysipelatoid  inflammation  of  the  tissues  to  which  the  painful 
nerve  is  distributed.  Some  years  ago  I  was  much  surprised  at  observ- 
ing, in  a  women  aged  thirty-two,  a  patient  of  the  Chelsea  Dispensary, 
a  most  acute  attack  of  unilateral  erysipelas  of  the  face  and  head,  super- 
vening on  some  severe  and  frequently  recurring  attacks  of  Neuralgia, 
which  affected  all  three  divisions  of  the  trigeminus,  but  was  most  vio- 
lent in  the  branches  of  the  ophthalmic  division.  On  the  occurrence 
of  the  erysipelas,  the  acute  pain  subsided,  but  the  most  intense  ten- 
derness remained  for  some  days,  and  pressure  anywhere  in  the  track 
of  the  nerves  would  re-excite  a  momentary  spasm  of  pain.  Since  that 
time  I  have  been  constantly  on  the  look-out  for  similar  cases,  and 
have  observed  a  good  many  either  in  my  own  practice  or  that  of 
others.  In  several  instances  I  have  seen  Neuralgia  of  the  fifth  actually 


NEURALGIA.  151 

terminate  in  an  affection  undistinguishable  from  ordinary  erysipelas, 
limited  to  the  painful  parts:  in  four  of  these  cases  it  was  limited  to 
the  side  of  the  nose,  the  infra-orbital  and  frontal  regions.  But  the 
facts  bearing  on  a  connection  between  facial  neuralgia  and  erysipelas, 
are  by  no  means  limited  to  this.  In  twenty-two  cases  which  have 
come  under  my  care,  of  patients  suffering  either  from  typical  facial  tic, 
from  migraine,  or  from  clavus  hystericus,  I  have  discovered,  by  inquiry, 
the  existence  of  a  strong  tendency  to  erysipelatoid  inflammation  of 
the  parts  then  affected  with  Neuralgia.  An  attack  of  erysipelas  would 
be  brought  about  in  these  patients,  by  the  most  trivial  causes,  by  a 
slight  exposure  to  cold  winds,  or,  on  the  other  hand,  by  unusually 
depressing  fatigue,  or  emotion.  The  majority  of  these  patients  gave 
me  a  family  history  which  showed  a  marked  inherited  disposition  to 
neurotic  affections,  a  circumstance  which,  as  we  shall  hereafter  see,  is 
of  importance. 

Perhaps  the  most  striking  of  all  the  cases  which  have  come  under 
my  notice  is  one  which  was  obligingly  sent  to  me  by  Mr.  Ernest  Hart, 
and  which  I  have  already  published1  in  detail.  The  exciting  cause  of 
the  whole  train  of  phenomena  was  apparently  fright,  from  an  accident 
which  there  was  no  reason  to  suppose  inflicted  any  direct  physical  in- 
jury. The  sequence  of  events  was:  (1)  abrupt  cessation  of  menses, 
with  hysteric  depression ;  (2)  severe  neuralgia  of  the  first  and  second 
divisions  of  the  fifth,  quickly  producing  iritis,  with  effusion  of  lymph  ; 
(3)  erysipelas,  exactly  limited  to  the  skin  of  the  painful  parts,  and  as 
it  were  supplanting  the  Neuralgia. 

The  concurrence  of  iritis  with  the  erysipelas,  in  this  case,  is  a  most 
interesting  fact,  as  showing  a  general  tendency  to  paralysis  of  the 
vessels  in  the  affected  district,  which  will  be  much  dwelt  on  in  the 
section  on  pathology.  The  connection  of  iritis  with  Neuralgia  is  a 
subject  which,  although  only  quite  recently  mooted,  already  assumes 
an  extraordinary  magnitude,  and  may  yet  lead  to  pathological  and 
therapeutical  discoveries  of  first-rate  importance.  For  my  own  part 
I  do  not  hesitate  to  express  the  belief  that  the  very  vague  and  ill-de- 
fined disease  known,  in  common  phrase,  as  "  Rheumatic  iritis,"  is 
destined  to  be  almost,  if  not  quite,  banished  to  limbo  ;  for  that  careful 
observation  will  prove  the  cases  so  denominated  to  be  nearly  all 
capable  of  classification  as  "  Neuralgic  iritis." 

The  symptoms  which  characterize  this  malady  are  as  follows :  The 
patient  first  of  all  complains  (usually  after  exposure  to  cold  wind,  or 
damp,  or  both)  of  pain  round  the  orbit,  which  gradually  increases  to 
a  pitch  of  great  severity,  but  which  exhibits  marked  intermissions  or 
at  least  remissions.  The  vessels  of  the  conjunctiva,  but  more  particu- 
larly of  the  sclerotic,  then  become  injected.  Last  of  all  the  iris  itself 
becomes  cloudy,  and,  in  severe  cases,  actual  deposits  of  lymph  take 
place.  I  cannot  hesitate  to  say,  from  careful  inquiries  into  the  past 
history  of  such  patients,  that  this  kind  of  affection  occurs  quite  as  fre- 
quently in  persons  who  have  never  shown  any  distinctive  rheumatic 
tendencies  as  in  those  who  have.  On  the  other  hand  there  is  nearly 

1  Lancet,  1866,  vol.  ii.  p.  548. 


152  DISEASES    OF    THE    NERVES. 

always  a  recognizable  history  of  tendencies  towards  neuralgic  affections 
,of  one  sort  or  another.  And  indeed,  with  regard  to  the  whole  series 
of  so-called  chronic  rheumatic  affections  of  fibrous  membranes,  it  must 
be  remembered  that  there  is  reason  to  doubt  whether,  on  careful 
analysis,  their  local  symptoms  can  be  grouped  into  any  intelligible 
unity.  It  seerns  far  more  likely  that,  as  the  consequences  of  spinal 
irritation  become  more  perfectly  known,  the  whole  group  of  such 
affections  will  be  resolved  into  particular  cases  of  centric  nervous 
irritation. 

And  finally,  it  may  be  noted  that  this  variety  of  iritis  is  greatlv 
more  amenable  to  the  influence  of  quinine  than  to  that  of  any  other 
remedy ;  in  fact,  beyond  the  use  of  belladonna  to  prevent  pupillary 
adhesion,  no  other  treatment  is  required. 

Herpes,  as  a  complication  of  dorso-intercostal  Neuralgia,  has  been 
already  referred  to.  Although  not  so  commonly,  it  may  probably 
attend  Neuralgia  of  any  superficial  nerve.  For  instance,  the  occurrence 
of  a  regular  facial  herpes  zoster  has  been  considered  by  many  authors 
not  so  much  a  rarity  as  an  impossibility.  But  various  single  cases 
have  been  recorded  by  individual  observers  of  late  years,  and  in  a 
very  valuable  paper  on  unilateral  herpes  in  the  London  Hospital 
Eeports  for  1866,  Mr.  Jonathan  Hutchinson  reckons  up  fourteen  cases, 
including  several  which  came  under  his  own  observation ;  some  of 
them  are  mentioned  to  have  been  accompanied  by  Neuralgia  of  the 
fifth.  In  one  of  these  cases,  in  which  the  Neuralgia  was  particularly 
severe,  the  herpetic  vesicles  were  followed  by  ulcers,  which  left  con- 
siderable scars  on  the  forehead.  I  have  myself  seen  herpes  the 
attendant  of  two  cases  of  cervico-brachial  Neuralgia,  in  one  of  which 
the  ulcerations  following  the  vesicles  were  a  cause  of  severe  suffering; 
and  in  one  instance  of  sciatica  in  my  practice  there  occurred  enor- 
mous vesicles,  or  rather  bullas,  on  the  back  of  the  calf,  which  formed 
most  troublesome  and  exquisitely  painful  ulcers.  Barensprung1  records 
a  similar  caser  in  which  the  irritation  of  the  sciatic  was  secondary  to 
psoas  abscess. 

The  tendency  of  deeper  tissues  to  be  affected  in  an  inflammatory 
manner  as  a  consequence  of  Neuralgia,  which  is  especially  shown  in 
the  cases  of  neuralgic  iritis,  receives  every-day  illustration.  In  fact, 
the  painful  points  so  universally  observed  in  severe  or  inveterate 
cases  are  probably  produced  by  a  subacute  inflammation,  first  of  the 
fibrous  membranes  (periosteum  or  fascia)  in  contact  with  the  nerve  at 
points  where  it  comes  out  from  a  deeper  to  a  more  superficial  position, 
and  further  (in  some  cases)  to  all  the  subcutaneous  tissues  for  an  inch 
or  two  round.  In  one  of  the  cases  of  cervico-brachial  Neuralgia 
already  referred  to,  a  bright  red  painful  spot,  as  large  as  half-a-crown, 
appeared  on  the  outer  side  of  the  arm  ;  there  was  dense  thickening  of 
tissues  in  this  situation,  and  the  resemblance  to  an  inflamed  syphi- 
litic node  was  remarkable.  The  neuralgic  origin  was,  however,  unmis- 
takable. Among  the  cases  of  facial  herpes  collected  by  Hutchinson, 

1  Loc.  cit. 


NEURALGIA.  153 

there  are  several  in  which  serious,  or  even  irremediable  damage  was 
inflicted  on  the  eye  by  general  inflammation  of  its  tissues. 

DIAGNOSIS. — The  diagnosis  of  neuralgic  affections  from  others  which 
may  involve  pain  is,  on  the  whole,  not  difficult,  if  we  are  able  to 
extract  from  the  patient  a  full  account  of  his  history.  The  essential 
points  for  observation  are :  1.  The  situation  and  direction  of  the 
pain,  whether  this  is  unilateral,  whether  it  corresponds  to  the  course 
of  a  recognizable  nerve  branch  or  branches.  2.  Whether  it  is  inter- 
mittent, or  markedly  remittent.  The  points  of  history  which  are 
most  important  are  :  1.  Whether  the  patient  has  suffered  Neuralgia 
before,  and  if  not,  whether  neuralgias,  or  neurotic  disease  of  any 
kind  have  prevailed  in  his  family.  2.  Whether  the  attack  was  pre- 
ceded by  nervous  depression,  or  was  ushered  in  by  distinct  numbness 
or  tingling.  3.  Whether  the  immediate  excitant  appeared  to  be  cold 
or  damp,  or  both,  or  a  severe  nervous  shock,  or  a  direct  physical 
injury.  4.  (If  the  affection  has  lasted  some  time)  whether  there  has 
occurred  any  development  of  secondary  tender  points  in  the  situations 
where,  as  above  described,  they  might  be  expected.  5.  Whether  the 
patient  has  suffered  from  secondary  affections  of  glands  (e.  g.,  lachry- 
mation,  in  the  case  of  facial  pain)  during  the  attacks,  or  of  temporary 
congestion  of  surfaces  (<:.  g.,  of  the  conjunctiva)  in  the  same  case,  or 
from  alterations  of  epithelium  or  hair,  or  herpetic  eruptions,  or 
erysipelatoid  inflammation  of  the  skin  corresponding  to  the  distribu- 
tion of  the  affected  nerves. 

The  affirmative  answer  to  any  of  these  questions  is,  pro  tanto,  in 
favor  of  the  genuinely  neuralgic  character  of  the  disorder;  and, 
indeed,  the  union  of  features  1  and  2,  under  the  heading  of  "  observa- 
tion," with  one,  or  still  more  with  two  or  three,. of  the  "historical" 
facts,  would  be  pretty  well  decisive  in  this  sense. 

The  main  source  of  embarrassment,  in  difficult  cases  of  diagnosis,  is 
the  impossibility  which  we  sometimes  encounter  of  getting  a  clear 
history.  This  is  especially  apt  to  occur  when  we  are  called  to  the 
patient  not  so  much  on  account  of  the  primary  neuralgic  affection  as 
because  of  severe  secondary  consequences  that  happen  to  have  arisen. 
For  instance,  in  a  case  of  severe  Neuralgia  of  the  fifth,  attended  with 
periosteal  inflammation  round  the  orbit,  or  with  intense  conjunctivitis, 
and,  it  may  be,  corneitis,  or  even  iritis,  the  history  related  is  likely 
enough  to  lack  explicit  details  of  the  primary  affection.  It  is  neces- 
sary to  inquire  very  strictly  whether  the  pain,  when  it  first  occurred, 
was,  or  was  not,  accompanied  by  tenderness  on  pressure  ;  and  whether 
this  simple  pain  markedly  preceded  the  organic  lesions. 

Another  serious  difficulty  arises,  not  unfrequeutly,  in  distinguishing 
between  true  Neuralgia,  and  that  form  of  pain  which  is  vaguely 
called  hysteric ;  and  also  between  the  former,  and  Myalgia  not 
associated  with  the  hysteric  diathesis.  The  great  characteristic  of 
true  Neuralgia  is  the  limitation  of  the  pain  to  the  course  of  re- 
cognizable branches  of  nerves,  as  opposed  to  the  diffused  character 
both  of  hysteric  and  neuralgic  pains.  A  history  of  intense  hysteric 
predisposition  may  help  the  diagnosis  in  some  cases,  and  a  history 
of  overwork  done  by  under- nourished  muscles  may  clear  it  up  in 


15-i  DISEASES    OF    THE    NERVES. 

others.  But  hysterical  persons  may,  and  sometimes  do,  suffer  from 
true  Neuralgia.  And  again,  it  is  very  common  for  hysteric  patients 
to  develop  tender  points  in  certain  situations  (especially  beneath  the 
left  mamma,  in  the  epigastrium,  and  at  various  situations  along  the 
vertebral  fossas  which  lodge  the  great  muscles  of  the  back),  which 
bear  a  superficial  similarity  to  the  tender  points  developed  in  long- 
standing Neuralgia.  The  more  generalized  hypersesthesia  of  the  skin 
which  usually  accompanies  these  symptoms,  when  they  are  due  to 
hysteria,  will  seldom,  be  observed,  however,  in  true  Neuralgia ;  and 
the  remarkable  affections  of  volition  which  mostly  accompany  the 
hysteric  diathesis  rarely  occur  in  Neuralgia  pure  and  simple.  A 
means  of  diagnosis  between  hysteric  hyperaBsthesia  and  the  true  Neu- 
ralgia which  I  have  found  most  useful  is  the  use  of  Faradisation.  It 
has  a  strikingly  inactive  effect  in  the  former,  but  acts  much  more 
slowly,  or  not  at  all,  in  true  Neuralgia. 

It  is  almost  impossible  to  lay  down  rules  of  diagnosis,  in  this  place, 
between  neuralgia  pure  and  simple,  and  that  which  accidentally  occurs 
from  a  nerve  becoming  squeezed,  or  otherwise  damaged,  in  the  pro- 
gress of  tumours  or  other  organic  diseases  external  to  it.  The  reader 
must  be  referred  to  the  diagnostic  characters  mentioned  in  the  treatises 
on  such  diseases  for  the  means  of  distinction. 

The  neuralgic  pains  which  usher  in  locomotor  ataxy,  are  highly 
peculiar,  and  their  diagnosis  from  ordinary  Neuralgia  must  be  learned 
by  studying  the  article  on  the  former  disease. 

PROGNOSIS. — The  prognosis  of  Neuralgia  is  nearly  always  an  un- 
certain matter.  The  simplest  case  is  when  a  clearly  malarial  history 
can  be  made  out,  and  when  the  blood  infection  has  not  lasted  too 
long:  here  we  may  expect  a  speedy  cure  by  appropriate  treatment. 
The  least  complicated  varieties  of  traumatic  Neuralgia — those  in 
which  the  irritation  is  only  kept  up  by  some  mechanical  irritation 
(e.<7.,  a  foreign  body  lodged,  or  a  tight  cicatrix  making  pressure) — of 
course  offer  a  good  chance  of  cure  by  surgical  interference.  Among 
the  Neuralgias  which  are  more  purely  of  internal  origin,  those  are 
chiefly  to  be  regarded  as  benign  which  occur  in  young  subjects;  and 
next  to  youth  in  favourable  influence  on  the  prognosis  comes  the  fact 
of  otherwise  unbroken  health.  Neuralgia  becomes  progressively  less 
curable  in  each  successive  decade  of  life,  and  more  especially  after 
the  commencement  (at  whatever  nominal  age)  of  the  symptoms  of 
organic  degeneration.  Very  formidable,  in  all  cases,  is  the  fact  that 
the  patient's  family  have  been  liable  either  to  severe  Neuralgias,  or 
to  other  grave  neuroses.  And  when  a  patient  with  such  a  family 
history  is  first  attacked  with  a  Neuralgia  after  he  has  already  entered 
on  the  period  of  organic  degeneration,  his  chances  of  complete  re- 
covery must  be  reckoned  very  small.  Moreover,  such  a  Neuralgia 
is  not  unfrequently  the  first  warning  of  a  degeneration  of  the  centres, 
which  will  end  with  softening  of  the  brain. 

These  are  the  fundamental  points  in  prognosis.  A  less  essential, 
but  still  important,  class  of  momenta  are  the  circumstances  of  the 
patient's  life ;  how  far,  for  instance,  he  is  likely  to  be  exposed  to  the 


NEURALGIA.  155 

hostile  influences  of  cold,  damp,  and  privation,  with  the  disorders 
which  they  tend  to  engender ;  and  how  far  there  may  be  unavoidable 
exposure  to  the  influences  of  mental  distress,  or  of  the  weariness  of 
an  objectless  life. 

PATHOLOGY  AND  ETIOLOGY. — These  two  subjects,  in  the  case  of 
Neuralgia,  are  inextricably  mixed;  nor  is  it  possible  to  discuss  the 
one  without  constant  reference  to  the  other.  They  are  so  mixed, 
firstly,  because  there  is  no  sufficient  basis  of  anatomical  fact  to  support 
a  "pathology,"  in  the  ordinary  sense;  and  secondly,  because,  in  addi- 
tion to  the  philosophical  difficulties  which  always  beset  the  construction 
of  an  etiological  system,  there  are,  in  the  case  of  Neuralgia,  special 
obstacles  to  the  decision  as  to  what  is  "cause"  and  what  "effect" 
arising  from  the  necessity  of  regarding  a  neuralgic  person  as  a  mere 
offshoot  of  a  certain  family  beset  with  peculiar  tendencies,  rather  than 
as  an  individual  who  forms  his  own  physical  destiny  by  the  manner 
and  circumstances  of  his  life. 

Of  facts  tending  to  elucidate  the  morbid  anatomy  of  Neuralgia  there 
are  very  few.  This  necessarily  follows  from  the  rarity  with  which 
neuralgic  patients  die  under  circumstances  which  lead  to  any  careful 
examination  of  the  nerves  and  nerve  centres.  Among  the  very  few 
recorded  cases  which  show  anything  positive  is  the  remarkable  one 
related  by  Romberg.1  The  patient  was  a  victim  to  the  severest  form 
of  facial  Neuralgia,  "of  the  period  of  bodily  degeneration"  such  as  I 
have  described  it.  The  Gasserian  ganglion  of  the  painful  nerve  was 
almost  destroyed  by  the  pressure  of  an  internal  carotoid  aneurism, 
the  trunk  and  posterior  root  of  the  nerve  were  completely  degenerated, 
and  the  atrophic  process  had  extended,  in  less  degree,  to  the  nerve  of 
the  opposite  side. 

This  case,  alone,  of  course,  proves  nothing  as  to  the  general  question 
of  the  pathology  of  Neuralgia.  But  it  teaches  a  notable  fact,  that  the 
extremity  of  pain  can  be  suffered  in  a  nerve  in  which  sensation  would 
soon  have  become  extinct  by  dissolution  of  the  connection  between 
centre  and  periphery.  It  is  imaginable  that  a  not  less  real,  but  less 
advanced  and  less  coarsely  obvious  atrophic  change  may  have  been 
present  in  every  case  of  Neuralgia,  even  where  dissection  has  failed  to 
reveal  anything  amiss.  It  must  be  remembered  that  the  microscopic 
study  of  morbid  changes  in  nerve  tissues  is  even  now  only  in  its  infancy. 
It  would  be  vain  to  occupy  a  large  space,  in  a  practical  treatise,  with 
disquisitions  on  a  subject  at  present  so  obscure  as  the  pathology  of 
Neuralgia;  I  shall  therefore  content  myself  with  stating  the  hypo- 
thesis which  appears  most  probable  to  me,  and  the  mere  outline  of 
the  reasons  which  incline  me  to  adopt  it. 

I  think  it  most  probable  that  in  all  cases  of  Neuralgia  there  is  either 
atrophy,  or  a  tendency  to  it,  in  the  posterior  or  sensory  root  of  the 
painful  nerve,  or  in  the  central  gray  matter  with  which  it  comes  in 
closest  connection.  The  following  are  the  heads  of  the  argument : — 

1.  Neuralgia  is  eminently  hereditary.  It  is  constantly  observed  to 
prevail  in  particular  families,  breaking  out  in  successive  generations 

1  Diseases  of  Xervous  System,  Syd.  Soc.  Traus.,  vol.  i. 


156  DISEASES    OF    THE    NERVES. 

and  various  individuals.  But  what  is  even  more  important  to  notice 
is  the  fact  that  these  neuralgic  families  are  almost  invariably  also  dis- 
tinguished by  a  tendency  to  the  severer  neuroses — insanity,  cerebral 
softening,  paralysis,  epilepsy,  hypochondriasis,  or  an  uncontrollable 
tendency  to  alcoholic  excess ;  and  very  often  in  the  various  members 
of  the  same  family  we  may  observe  the  alternation  of  all  these  affec- 
tions, and  of  Neuralgia,  in  various  members. 

2.  Such  hereditary  tendencies  in  a  race  seem  strongly  to  suggest  a 
tendency  to  imperfection  in  the  congenital  construction  of  the  central 
nervous  system ;  so  that  we  may  imagine  that  certain  cells  and  fibres 
of  this  system  are,  in  a  large  proportion  of  that  race,  built,  as  it  were, 
only  to  live  with  perfect  life  for  a  short  term.    The  weak  spot  may  be 
in  one  place  in  this  person,  in  another  place  in  that. 

3.  Given  such  a  weak  spot  congenitally  present,  all  hostile  influ- 
ences will  tell  more  heavily  on  it  than  on  the  rest  of  the  organs. 
The  depressing  influence  of  cold  applied  to  the  periphery,  of  a  wound 
of  the  trunk  or  branches  of  a  nerve,  of  a  severe  shock  (mental  or 
physical)  to  the  nervous  centres  generally,  or  of  continued  alcoholic 
excesses,  will  suffice  to  throw  the  imperfectly  constructed  cells  into 
a  state  of  positive  disease,  which  may  end  in  decided  atrophy.     Even 
in  the  absence  of  any  special  external  cause,  the  depressing  influence 
on  the  nervous  centres  produced  by  the  great  crises  of  puberty,  child- 
bearing,  the  involution  of  the  female  organs  at  the  grand  climacteric, 
and  still  more  the  partial  failure  of  nutrition  which  the  arterial  dege- 
neration of  advanced  life  would  cause — any  of  these  may  suffice  to 
start  the  local  morbid  process. 

4.  A  very   weighty  argument  in  favour  of  the  idea  that  central 
mischief  is  a  factor  in  all  cases  of  Neuralgia  is  the  great  frequency 
of  complications,  such  as  have  been  described,  in  which  various  nerve- 
fibres,  quite  distinct  from  those  which  are  the  seat  of  pain,  and  con- 
nected with  these  only  through  the  centre,  are  secondarily  affected. 

5.  Those  cases  in  which  a  localized  peripheral  lesion  is  the  imme- 
diate excitant  also  require  for  their  explanation  the  assumption  of  a 
peculiarity  in  the  individual,  as  one  factor,  and  that  the  most  impor- 
tant, in  the  production  of  the  Neuralgia.     For  of  hundreds  of  per- 
sons to  whom  exactly  similar  lesions  happen  every  year,  not  more 
than  two  or  three,  perhaps,  experience  any  Neuralgia;  and  these  two 
or  three  will,  I  believe,  be  invariably  found  to  belong  to  neurotic 
families. 

6.  The  only  cases  to  which  the  theory  of  congenital  central  imper- 
fection appears  neither  applicable  nor  necessary  are  those  in  which  a 
pressure,   ulceration,  or  other  lesion  extending  from  neighbouring 
tissues  towards  the  nerve,  maintains  a  constant  depressing  centripetal 
influence  which  it  is  not  difficult  to  suppose  might  impair  the  vitality 
of  the  posterior  root,  or  of  the  central  gray  matter. 

7.  Certain  influences,  especially  that  of  excessive  drinking,  which 
notoriously  tend  to  produce  degeneration  of  the  nervous  centres,  are 
powerful  predisposers  to  the  production  of  Neuralgia  of  the  inveterate 
type.   Moreover,  the  descendants  of  drunkards,  among  other  evidences 
of  an  enreebled  nervous  organization,  are  decidedly  prone  to  Neuralgia. 


NEURALGIA.  157 

So  frequently  have  I  made  the  discovery  that  neuralgic  patients  have 
had  drunken  parents,  that  I  cannot  suppose  the  coincidence  to  be 
accidental. 

TREATMENT. — The  treatment  of  Neuralgia  may  be  classified  under 
three  heads.  The  first  division  includes  all  remedial  measures  which 
are  intended  to  improve  the  general  nutrition,  including  that  of  the 
nervous  system,  or  to  remove  any  vicious  condition  of  the  blood  which 
may  impair  nervous  function.  The  second  division  includes  the  nar- 
cotic stimulant  remedies.  The  third  division  comprises  all  the  remedies 
which  are  destined  to  exert  a  direct  influence  upon  the  affected  nerve. 

1.  Constitutional  treatment. 

(a.)  Under  the  head  of  nutritive  remedies  for  Neuralgia,  by  far  the 
most  important  sub-class  is  the  series  of  animal  fats.  There  is  a 
theoretical  basis  for  the  use  of  these  substances  which  it  is  impossible 
to  ignore,  although  I  have  no  desire,  in  the  present  state  of  our 
knowledge,  to  insist  too  absolutely  upon  it.  In  some  way  or  other,  fat 
must  undoubtedly  be  applied  to  the  nutrition  of  the  nervous  system, 
if  this  is  to  be  maintained  in  its  organic  integrity  ;  since  fat  is  one  of 
the  most  important,  if  not  the  most  important,  of  its  organic  ingredients. 
But  if  our  theoretical  ideas  on  this  point  be  as  yet  deficient  in  the 
exactness  which  is  to  be  desired,  there  can  be  no  doubt,  I  think,  that 
the  practical  lessons  which  they  would  teach  are  abundantly  verified 
in  experience.  If  we  take,  for  instance,  the  class  of  Neuralgias  which 
are  most  plainly  and  indubitably  connected  with  impaired  nutrition — 
those  of  advanced  life,  and  particularly  the  inveterate  forms  of  facial 
tic  douloureux — there  is  the  strongest  ground,  in  the  result  of  expe- 
rience, for  insisting  upon  the  value  of  this  class  of  remedies.  To  Dr. 
Eadcliffe  belongs  the  merit  of  having  been  chiefly  instrumental  in 
bringing  forward  this  therapeutical  fact  in  this  country,  and  it  is 
one  which  I  have  had  repeated  occasions  to  verify.  It  is  a  very 
singular  circumstance,  which  also  was  first  pointed  out  by  Dr. 
Eadcliffe,  that  neuralgic  patients  are,  in  the  majority  of  instances, 
found  to  have  cherished  a  dislike  to  fatty  food  of  all  kinds,  and  to 
have  systematically  neglected  its  use.  I  have  also  obtained  strong 
evidence  that  this  is  the  general  rule,  and  the  reverse  a  rare  excep- 
tion. And  it  has  several  times  occurred  to  me  to  see  patients 
entirely  lose  neuralgic  pains,  which  had  troubled  them  for  a  consider- 
able time,  after  the  adoption  of  a  simple  alteration  in  their  diet, 
by  which  the  proportion  of  fatty  ingredients  in  it  was  considerably 
increased. 

Cod-liver  oil  occupies  the  highest  rank  among  fatty  remedies  ; 
where  it  does  not  immediately  disagree  with  the  stomach,  this  oil  is 
the  best  fat  to  employ.  But  in  other  cases  butter,  and  especially 
cream,  may  be  employed  with  great  advantage;  and  in  fact  one  of 
the  most  successful  examples  of  the  treatment  of  Neuralgia  which 
I  record  was  treated  solely  by  the  administration  of  Devonshire 
cream  in  increasing,  and  finally  in  very  large  quantities.  Even  the 
vegetable  olive  oil,  though  far  inferior  to  animal  fats  as  a  general 
rule,  may  occasionally  be  used  with  good  effect.  It  is  necessary  in 
many  cases  to  make  a  series  of  trials,  before  we  arrive  at  the  par- 


158  DISEASES    OF    THE    NERVES. 

ticular  form   of  fatty  food  which  is  best   suited   to   the   particular 
patient. 

(b)  The  various  preparations  of  iron  are  of  use,  so  far  as  I  know, 
only  in  cases  which  are  marked  by  the  existence  of  actual  anasmia. 
For  patients  who  possess  well  globulated  blood   (as  indicated  not 
merely  by  the  colour  of  the  face,  but  by  that  of  the  mouth  and  tongue, 
especially  by  the  freedom  of  the  latter  from  teeth- markings,  and  by 
the  absence  of  the  drowsiness,  muscce  volitantes,  &c.,  which  indicate 
defective   blood-nutrition   of  the   brain)  I  do  not  believe  that  iron 
treatment  has  any  value.     The  carbonate,  in  large  doses,  is  the  best 
form,  when  iron  is  needed  at  all. 

(c)  The  employment  of  the  so-called  special  nerve-tonics  is  of  great 
use  in  some  cases,  of  none  at  all  in  others.     Quinine,  arsenic,  and 
zinc  (in  various  preparations)  are  the  only  medicinal  substances  of 
this  class  which  possess  any  solid  claims  to  efficacy. 

With  regard  to  the  efficacy  of  quinine  there  are  the  most  conflict- 
ing opinions,  except  in  one  respect.  No  one  doubts  that  in  the 
Neuralgias  which  are  of  malarious  origin  this  medicine,  though  not 
infallible,  is  extremely  efficacious.  It  should  be  administered,  in  all 
cases  which  from  their  regular  intermittence  leave  room  for  a  suspi- 
cion that  this  may  be  their  nature,  in  full  doses  (five  to  twenty  grains) 
shortly  before  the  time  at  which  the  attack  of  pain  is  expected;  in 
fact  just  in  the  way  which  proves  most  effective  in  the  treatment  of 
regular  ague.  If  after  three  or  four  doses  a  decided  improvement  is 
not  effected,  the  probability  is  great  that  the  Neuralgia  is  not  malarial. 
Nevertheless,  arsenic  may  subsequently  be  tried  if  other  means  (to  be 
presently  described)  prove  ineffectual. 

In  a  certain  number  of  non-malarial  cases,  also,  quinine  produces 
good  effects;  but  there  is  no  need,' nor  is  it  advisable,  to  employ  it 
in  such  large  doses.  From  two  to  three  grains,  three  times  a  day,  is 
the  largest  quantity  which  is  likely  to  be  of  any  use,  if  my  own  ex- 
perience is  worth  anything.  I  know  of  no  circumstances  which  indi- 
cate beforehand  that  quinine  will  be  useful  in  non-malarial  cases, 
except  that  it  seems  always  much  more  effective  in  Neuralgia  of  the  oph- 
thalmic branches  of  thefifth,  than  in  other  non-malarial  Neuralgias. 

With  regard  to  other  non-malarial  Neuralgias  I  share  Valleix's 
opinion,  that  it  is  far  from  being  frequently  useful. 

Arsenic  is  a  more  widely  applicable  remedy ;  for  it  is  useful  in 
many  cases  both  of  the  malarial  and  of  the  non-rnalarial  type.  In 
the  former,  it  should  be  given,  probably,  in  full  doses,  ten  minims, 
increasing  to  thirty,  of  Fowler's  solution,  three  times  a  day.  In  the 
non-malarial  forms,  the  ordinary  tonic  dose  of  five  minims  of  Liq. 
Arsenicalis,  three  times  a  day,  or  ^5  grain  of  Arseniate  of  soda  in  pill, 
with  extract  of  hop,1  will  effect  all  the  good  which  this  medicine  can 
produce.  The  ordinary  precautions  must  of  course  be  observed, 
as  in  any  other  case  where  we  employ  arsenic.  There  is  one  form 
of  Neuralgia,  however,  which  merits  special  mention  in  relation  to 

1  Dr.  Radcliffe  tells  me  he  finds  that  extract  of  hop  enables  arsenic  to  be  better 
tolerated  thau  when  given  alone. 


NEURALGIA.  159 

arsenical  treatment;  I  mean  the  specially  neurotic  form  of  angina 
pectoris.  In  France  this  remedy  is  extensively  used  for  cardiac 
Neuralgia.  I  have  myself  seen  most  remarkable  relief  afforded 
by  arsenic  in  this  complaint,  and  an  extraordinary  tolerance  of  the 
system  to  large  doses  of  it.  Very  recently  Dr.  Philipp  has  put  on 
record  a  most  interesting  case  of  the  kind.1  There  are,  indeed,  some 
patients  whose  alimentary  canal  is  too  irritable  to  bear  this  remedy 
at  all ;  but  it  is  usually  well  borne,  and  often  extremely  efficacious. 
Arsenic  may  also  be  effectively  administered  by  subcutaneous  injec- 
tion. 

The  preparations  of  zznc,  and  more  especially  the  valerianate,  enjoy 
a  high  reputation  with  some  practitioners.  It  is  necessary  to  record 
this  fact;  but  I  cannot  say  that  I  have  ever  seen  any  good  result, 
which  could  be  confidently  attributed  to  these  remedies,  in  Neuralgia. 

(d)  Last,  among  the  constitutional  remedies,  we  have  to  mention 
those  which  are  directed  against  a  real  or  presumed  depravation  of 
the  blood  by  some  special  poison.  Neuralgia  may  certainly  arise 
from  syphilis ;  but  then  it  is  probably  always  due  to  a  local  deposit 
somewhere  in  the  course  of  the  affected  nerve.  Where  this  can  be 
suspected  iodide  of  potassium  should  be  administered  in  large  doses  ; 
and  if  this  fails,  the  bichloride,  or  biniodide  of  mercury,  in  small 
doses.  Neuralgia  is  said  to  have  frequently  a  gouty  origin  :  but  the' 
facts  on  which  this  statement  rests,  perhaps  hardly  warrant  a  decided 
opinion.  They  scarcely  amount  to  more  than  this,  that  in  a  certain 
ill-defined  group  of  cases,  the  subjects  of  which  are  perhaps  more 
often  than  not  of  a  gouty  constitution,  a  form  of  Neuralgia  occurs 
which  yields  more  speedily  to  treatment  with  colchicum  than  to  any 
other  remedy.  Twenty  to  thirty  minims  of  the  tincture  or  the  wine, 
three  times  a  day,  will  be  sufficient;  and  if  a  marked  good  effect  be 
not  produced  in  two  or  three  days,  the  medicine  should  be  abandoned, 
or  even  earlier,  if  any  tendency  to  weakness  or  irregularity  of  the 
heart's  action  be  perceived. 

"Kheumatic"  Neuralgia  is  a  phrase  which,  under  the  precautions 
above  indicated,  must  still  be  retained,  as  signifying  a  class  of  cases 
in  which  inflammation  of  circumjacent  fibrous  tissues  seerns  to  cause 
the  neuralgic  pain  by  producing  mechanical  damage  to  the  nerve. 
Iodide  of  potassium  in  five  to  ten  grain  doses  twice  or  thrice  daily  is 
often  useful ;  causing  the  absorption  of  local  deposits,  or  rather  of 
local  proliferations  of  fibrous  tissue.  Even  in  cases  where  the  Neu- 
ralgia was  the  primary  affection,  and  the  fibrous  hypertrophy  second- 
ary to  it,  the  local  tenderness  and  swelling  appear  to  be  often  dimi- 
nished by  the  use  of  this  remedy.  I  have  never  seen  colchicum  pro- 
duce the  slightest  benefit  in  these  cases,  in  which  local  tenderness  is 
a  prominent  symptom. 

2.  We  have  now  to  consider  the  large  group  of  narcotic  stimulant 
remedies  for  Neuralgia.  In  this  class,  I  include  not  only  the  sub- 
stances generally  recognized  as  belonging  to  it,  such  as  opium,  bella- 
donna, alcohol,  &c.  &c.,  but  also  many  others,  such  as  ammonia,  tur- 

1  Berlin.  Klin.  Wochensch.  4,  1865. 


160  DISEASES    OF    THE    NERVES. 

pentine,  &c.,  which  are  commonly  spoken  of  merely  as  "stimulants:" 
and  also  substances  which,  like  aconite,  are  ordinarily  ranked  either 
as  pure  "sedatives"  or  as  "aero-narcotics."  I  shall  not  retrace  here 
the  arguments  which  I  have  given  at  large,  in  my  work  on  "  Stimu- 
lants and  Narcotics,"1  to  prove  that  all  these  substances  possess  the 
common  property  of  assisting  nerve  function  when  given  in  small 
doses,  and  of  paralyzing  it  when  given  in  excess. 

The  narcotic-stimulant  group  of  remedies,  when  administered 
internally  or  by  subcutaneous  injection,  may  be  said  to  hold  an 
intermediate  position  between  the  constitutional  and  the  local 
agencies  which  we  may  employ  against  Neuralgia.  On  the  one 
hand,  they  enter  the  general  circulation,  and  pervade  the  organism. 
On  the  other  hand,  it  may  be  suspected  that  in  many  cases  their 
effect  is  produced  mainly  by  a  local  action,  either  upon  the  central 
nuclei  of  affected  nerves,  or  perhaps  upon  their  spinal  ganglia. 

Indisputably,  at  the  head  of  all  this  class  of  remedies  stands 
opium.  And  we  may  consider  opium,  as  used  against  Neuralgia, 
to  be  fully  represented,  for  every  useful  purpose,  by  morphia.  But 
the  gastric  administration  of  opiates  can,  after  all,  be  only  considered 
as  palliative.  The  invention  of  the  subcutaneous  injection  (which 
was  imperfectly  forestalled  by  the  endermic  method),  has  thrown  quite 
'a  new  light  on  the  capabilities  of  opium  as  an  anti-neuralgic.  It 
may  be  confidently  said  that  in  the  right  use  of  this  remedy,  we  pos- 
sess the  means  of  permanently  and  rapidly  curing  very  many  cases, 
and  of  alleviating,  to  a  degree  quite  unknown  before,  the  suffering 
caused  by  even  the  most  inveterate  forms  of  Neuralgia. 

The  local  injection  of  alkaloids,  as  first  systematically  employed  by 
Dr.  Alexander  Wood,  is  a  proceeding  which  is  specially  applicable, 
in  my  opinion,  only  to  a  few  cases.  In  many  instances  the  nature  of 
the  integument  at  or  near  the  point  of  severest  pain,  is  such  as  to 
render  the  local  operation  inconvenient  or  even  impossible.  In  the 
great  majority  of  cases,  especially  those  which  are  seen  early,  the 
injection  may  be  more  advantageously  performed  in  some  indifferent 
place,  such  as  the  loose  skin  over  the  front  of  the  biceps  muscle,  or, 
in  fact,  in  any  place  where  a  fold  of  skin  can  be  conveniently  picked 
up.  The  substance  injected,  if  properly  dissolved  in  a  convenient 
quantity  of  fluid,  quickly  enters  the  general  circulation,  and,  in  a  large 
majority  of  instances,  produces  just  as  decided  an  effect  on  the  local 
nerve  pain,  as  if  it  had  been  locally  injected.  I  cannot  doubt  that, 
in  the  greater  number  of  cases,  the  "  local"  injection  is  such  only  in 
name;  the  injected  substance  producing  no  effect  till  it  has  entered 
the  absorbent  vessels  of  the  veins,  and  thence  travelled  all  round  the 
circulation  to  the  small  arteries,  either  of  the  spinal  and  ganglion ic 
centres,  or,  perhaps,  to  the  arteries  which  supply  the  peripheral 
branches  of -nerves.  The  discovery  of  the  great  utility  of  the  plan  of 
general,  as  opposed  to  local  injection,  is  due  to  Mr.  Charles  Hunter, 
and  is  of  the  highest  importance,  not  merely  as  a  practical  fact,  but  in 
the  suggestions  which  it  gives  as  to  the  general  subject  of  the  place  of 

1  London  :  Macmilhm.     IS  :4. 


NEURALGIA.  161 

origin  of  Neuralgia.  There  is,  however,  a  class  of  cases  in  which  the 
local  injection  of  morphia  becomes  desirable.  In  advanced  cases,  in 
which  very  great  local  hypersesthesia  exists,  and  there  is  reason  to 
think  that  thickening  and  hypertrophy  of  the  structures  round  the 
nerve  have  taken  place,  I  have  several  times  known  injection  at  a  dis- 
tant point  to  fail,  when  local  injection  of  the  same  substance,  in  the 
same  dose,  has  immediately  produced  a  marked  effect;  and  the  same 
thing  has  recently  been  pointed  out  to  me  by  several  medical  men. 
It  happens  sometimes,  however,  that  in  the  very  cases  which  seem 
most  to  demand  the  local  injection,  the  local  tenderness  makes  the 
operation  intolerably  painful:  in  such  a  case  I  should  recommend  a 
plan  which  Mr.  Hart  introduced  to  my  notice,  viz :  that  of  first  render- 
ing the  skin  insensible  with  ether  spray,  and  then  injecting.  As  the 
freezing  process  renders  the  tissues  quite  hard,  a  steel  canula  to  the 
syringe  is  needed  to  penetrate  them. 

As  regards  the  dose  to  be  employed,  I  cannot  but  think  that  the 
received  ideas  are  much  in  fault.  One  hears  constantly  of  as  much  as 
half  a  grain  or  one  grain,  even,  of  morphia  being  employed,  even  at 
the  outset.  That  such  quantities  are  necessary,  sometimes,  where  the 
cellular  tissue  injected  into  is  already  irritated  and  thickened,  I  have 
no  doubt ;  and  I  explain  it  by  the  hypothesis  that  a  good  deal  of  the 
injected  substance  never  enters  the  general  circulation,  nor  even  the 
vessels  of  the  part,  but  lies  encysted,  just  as  is  undoubtedly  the  case 
when  one  injects  an  irritant  substance  like  pure  chloroform  into  the 
cellular  tissue  anywhere.  But  I  am  quite  certain  that  when  injection 
of  any  non-ir-ritant  solution  of  morphia  into  a  healthy  cellular  tissue  is 
neatly  performed,  it  is  unnecessary  and  even  unsafe  to  commence  with 
larger  quantities  than  |  gr.  Both  in  my  own  practice  and  in  that  of 
a  friend,  I  have  known  so  little  as  \  gr.  produce  dangerous  symptoms 
of  poisoning  in  a  person  not  especially  sensitive  to  opium;  and  I 
am  convinced  that  the  activity  of  remedies  hypodermically  used  is 
generally  much  underrated.  I  have  produced  all  the  desired  effects 
by  injection  of  not  more  than  TV  gr.  in  slight  cases,  and  very  rarely 
indeed  (where  the  morphia  is  injected  at  an  indifferent  spot)  do  I 
increase  the  dose  beyond  |  gr.  The  best  medium  dose  is  £  gr.  and 
the  injections  should  be  repeated,  if  possible,  daily,  or  even  twice  a 
day  in  severe  cases.  In  visceral  Neuralgia,  it  need  hardly  be  said, 
we  are  obliged  to  be  contented  with  injection  at  an  indifferent  spot ; 
yet  (as,  e.g.,  in  ovarian  neuralgia)  we  sometimes  produce  excellent 
effects. 

Next  to  opium  in  value,  amongst  the  stimulant  narcotics,  is  bella- 
donna and  its  alkaloid  atropia.  The  value  of  belladonna,  as  given  by 
the  stomach,  is  confined  pretty  much,  according  to  my  experience,  to 
painful  affections  of  the  pelvic  organs,  on  the  sensory  (as  notoriously 
in  the  motor)  nerves,  of  which  it  seems  to  have  a  special  influence. 
In  doses  of  \  gr.  to  £  gr.  of  the  extract,  it  will  frequently  relieve 
ovarian  dysinenorrhcea,  as  also  some  forms  of  superficial  lumbo-abdomi- 
nal  Neuralgia.  But  by  far  the  most  important  use  of  belladonna  is 
by  the  subcutaneous  injection  of  atropia.  From  the  y-^  up  to  the  ^ 
of  a  grain  is  about  the  range  of  doses  for  adults;  and  I  can  confirm 
11 


162  DISEASES    OF   THE    NERVES. 

the  statements  of  Mr.  Hunter  that  by  repeated  applications  of  this 
treatment,  even  very  severe  and  inveterate  Neuralgias  are  often  greatly 
relieved,  and  sometimes  cured.  It  is  a  question  whether  there  is  not 
less  tendency  to  relapse  after  this  treatment  than  after  that  by  morphia. 
On  the  other  hand,  I  have  met  with  more  than  one  person  in  whom 
it  has  been  found  impossible  to  give  a  dose  sufficient  to  relieve  the 
pain  without  producing  distressing  head  symptoms. 

Next  in  value  to  morphia  and  atropia  comes  Indian  hemp,  which 
has  been  especially  brought  forward  by  Dr.  Reynolds.  A  good  ex- 
tract of  this,  in  doses  of  from  J  to  J  grain  or  (rarely)  1  grain,  given 
in  pill,  is  very  effective  in  some  forms  of  Neuralgia,  particularly  in 
clavus  hystericus  and  migraine.  Even  in  the  severest  and  most  in- 
tractable forms  it  often  palliates  greatly.  It  should  be  given  every 
night,  whether  there  be  then  pain  or  not. 

Muriate  of  ammonia  is  an  excellent  stimulant  remedy  in  migraine 
and  clavus,  and  in  some  cases  of  intercostal  neuralgia.  It  should  be 
given  in  10  to  20  gr.  doses.  In  cases  of  suspected  hepatic  neuralgia 
I  have  also  found  it  very  useful ;  and  I  believe  that  its  action  on  the 
liver  (in  disorders  of  secretion)  is  through  the  nervous  system  en- 
tirely. 

Sulphuric  ether,  which  in  the  severer  forms  of  superficial  neuralgias 
is  of  little  or  no  effect,  is  supremely  useful  in  certain  visceral  neural- 
gias. It  sometimes  relieves  gastralgia,  and  Neuralgia  of  uterine  or 
ovarian  origin,  with  magical  rapidity.  But  it  is  still  more  valuable 
in  the  most  purely  nervous  form  of  angina  pectoris.  I  have  now 
under  my  care  a  case  of  this  latter  affection,  which  I  am  convinced 
would  have  ended  fatally  long  since,  in  one  of  the  agonizing  attacks 
of  spasmodic  heart-pain,  but  for  the  discovery  that  by  taking  a  spoon- 
ful of  ether  immediately  on  its  commencement,  the  patient  can  greatly 
mitigate  the  attack.  This  patient  had  tried  arsenic,  but  from  the 
irritability  of  his  intestinal  canal,  could  not  take  it.  The  same  dose 
of  ether  has  continued  to  produce  the  same  happy  effect  on  each 
occasion  of  its  use  for  the  last  three  years. 

Aconite,  in  the  form  of  Fleming's  tincture,  is  of  very  great  use 
in  some  forms  of  Neuralgia,  especially  in  that  kind  of  ocular  neural- 
gia, with  secondary  inflammation,  which  is  so  frequently  called  rheu- 
matic iritis.  But,  unfortunately,  it  is  a  very  uncertain  remedy  in  one 
respect;  with  some  persons  it  produces  nausea,  burning  in  the  throat, 
and  a  sense  of  cardiac  depression,  with  doses  which  are  quite  harmless 
to  other  patients.  In  a  case  where  I  recently  employed  it,  in  only 
three  minim  doses  every  six  hours,  I  was  compelled  to  abandon  it 
after  the  third  dose,  from  the  intensely  depressing  effect  which  it  pro- 
duced. 

The  oil  of  turpentine  is  a  remedy  which  enjoys,  or  enjoyed,  con- 
siderable reputation  for  its  effect  in  a  certain  class  of  cases.  In  the 
more  obstinate  forms  of  sciatica  it  is  at  least  worth  a  trial,  although  it 
is  commonly  very  disagreeable  to  the  patient;  ten  minims,  three  times 
daily,  is  the  proper  dose. 

Still,  after  the  enumeration  of  all  the  narcotic  stimulant  substances 
which  have  been,  and  many  more  that  might  be  named,  it  would  be 


NEURALGIA.  163 

idle  to  pretend  that  any  of  them  are  to  be  compared,  for  wide  and 
general  efficacy,  to  the  subcutaneous  use  of  morphia  and  atropine,  and 
the  internal  use  of  Indian  hemp  in  small  doses. 

I  have  reserved  to  the  last,  under  the  head  of  Stimulant  Narcotics, 
what  must  be  said  about  alcoholic  drinks.  There  can  be  no  question 
about  the  power  of  alcohol  to  relieve  neuralgic  pains ;  it  is  as  distinct 
as  that  of  opium.  But  the  dangers  of  prescribing  it  as  a  remedy  are 
very  great,  since  the  patients  cannot  always  be  induced  to  use  it  in 
the  strictly  medical  manner  in  which  alone  it  is  safe.  Too  often,  in- 
stead of  employing  it  in  the  moderate  stimulant  doses  which  really 
are  of  service,  they  accustom  themselves  to  drowning  the  pain  with  a 
large  narcotic  dose,  and  they  thus  contract  a  liking  for  the  oblivion  of 
drunkenness.  It  is  of  much  consequence,  where  this  is  possible,  that 
they  should  be  forbidden  to  take  alcohol  otherwise  than  at  meal  times. 
If  once  they  are  induced  to  take  it  for  the  mere  relief  of  acute  pain, 
there  is  great  danger  that  they  will  drink  to  excess.  I  am,  neverthe- 
less, convinced  that  a  fixed  daily  allowance  of  wine  or  brandy  (beer 
more  rarely  agrees),  which  shall  contain  not  more  than  one  ounce  of 
absolute  alcohol,  is  a  decided  help  to  recovery  from  every  form  of 
Neuralgia;  and  in  the  case  of  persons  of  firm  character,  who  can  be 
trusted  to  exercise  self-control,  a  larger  quantity  than  this  may  some- 
times be  allowed.  Without  pretending  to  speculate  on  the  physio- 
logical reason  for  it,  I  must  add  my  testimony  to  the  fact,  which  has 
been  observed  by  Dr.  Radcliffe,  that  saccharine  liquors  and  saccharine 
foods,  except  in  very  moderate  quantities,  decidedly  disagree  with 
neuralgic  patients. 

3.  We  come  now  to  consider  the  external  remedies  for  Neuralgia. 
Incomparably  the  most  valuable  of  these  is  the  use  of  so-called 
counter-irritation  ;  that  is,  the  application  of  various  irritants  to  the 
skin.  Valleix  comes  to  the  conclusion  that  there  is  no  one  remedy 
which  approaches  blistering  in  value,  and  (putting  aside  the  recently 
discovered  hypodermic  treatment)  that  saying  remains  absolutely  true 
at  the  present  day.  It  is  to  be  observed  that  Valleix  latterly  always 
employed  the  milder  form  of  the  flying  blister.  Such  an  application 
as  this  to  the  foci  of  pain  must,  if  we  consider  it,  be  supposed  to  ex- 
cite a  directly  stimulant  effect  upon  the  painful  nerve.  This  kind  of 
blistering,  and  the  analogous  use  of  mustard  plasters,  have  always 
yielded  good  results,  in  my  experience,  solacing  even  when  they  did 
not  cure.  And  in  numerous  early  cases  one  or  two  flying  blisters, 
applied  successively  over  different  points  in  the  course  of  the  painful 
nerve,  have  at  once  and  permanently  arrested  the  disease.  It  is  a 
remedy  which  ought  always  to  be  tried  in  cases  of  any  severity,  espe- 
cially if  the  subcutaneous  injection  of  morphia  and  of  atropine  has 
failed.  There  is  one  method  of  blistering  which  I  have  recently  tried 
with  great  success,  viz.,  the  application  of  a  blister  close  to  the  spine, 
as  nearly  as  possible  opposite  the  intervertebral  foramen  from  which 
the  affected  nerve  issues.  The  effect  produced  is,  I  suppose,  a  reflex 
stimulation  through  the  posterior  branches.  This  method  is  of  course 
not  so  applicable  to  Neuralgias  of  the  fifth  as  to  those  of  spinal  nerves. 


164  DISEASES    OF   THE   NERVES. 

Yet  even  in  these,  blistering  of  the  nape  has  sometimes  appeared  to 
do  marked  good — through  the  occipital  nerve,  I  presume. 

The  application  of  various  stimulating  liniments  and  ointments  to 
the  skin  of  the  painful  parts  is  sometimes  very  useful.  Of  these  the 
use  of  chloroform  diluted  with  seven  parts  of  oil  or  soap  liniment  is 
far  the  most  efficacious.  This  produces  no  ansesthesia,  but  a  mild 
stimulation.  Strong  counter-irritation  may  be  produced  by  the  use 
of  tartar-emetic  or  of  veratrine  ointment. 

Ekctricity. — The  efficacy  of  various  forms  of  electricity  in  Neuralgia 
is  a  large  subject,  and  as  yet,  it  must  be  owned,  only  very  partially 
cleared  up.  The  comparative  merits  of  Faradisation  and  of  the  con- 
tinuous current  are  hardly  settled.  But  the  weight  of  testimony 
is  now  in  favour  of  the  belief  that  in  the  majority  of  instances  the 
continuous  current  is  the  most  valuable. 

As  regards  one  or  two  points,  one  may  speak  with  some  con- 
fidence. In  the  first  place  I  may  say,  after  extensive  trials  of  the 
ordinary  rotatory  (magneto-electric)  machine  for  the  induced  current 
that  this  method  of  treatment  is  most  unsatisfactory.  I  have  never 
seen  it  produce,  indisputably,  good  effects.  Secondly,  as  regards  that 
form  of  continuous  current  which  is  generated  by  Pulvermacher's 
chains,  I  am  reluctantly  obliged  to  give  up  the  hope  of  doing  any 
real  service  with  it  in  Neuralgia,  however  great  its  utility  is  in  other 
diseases.  As  is  remarked  by  Dr.  Althaus,  the  current  generated  by 
these  chains  is  too  irregular,  and  their  activity  is  too  soon  exhausted 
for  us  to  get  a  sufficiently  uniform  dose  of  electricity  applied  con- 
tinuously for  a  definite  period  by  their  means. 

It  appears  probable  that  we  shall  ultimately  find  that  for  neuralgic 
affections  of  all  kinds  the  most  useful  form  of  electrical  treatment  is 
by  the  continuous  current  generated  from  a  Bunsen's  or  a  Daniell's 
battery ;  and  that  the  three  principles  on  which  we  must  act  in 
its  use,  are :  1.  The  maintenance  of  the  current,  with  only  a  very 
few  breaks,  for  a  considerable  time.  2.  The  application  of  the 
positive  pole  over  the  seat  of  pain.  3.  The  employment  of  a  very 
low-tension  current.  I  am  informed  by  Mr.  J.  N.  Radcliffe,  whose 
experience  in  this  matter  is  very  large,  that  the  use  of  this  mode  of 
electrization  in  Neuralgia  is  as  yet,  in  his  opinion,  only  beginning  to 
be  developed,  but  that  it  promises  to  effect  great  things.  In  short, 
my  present  opinion  as  to  the  value  of  electricity  in  Neuralgia  may 
be  thus  expressed:  that  as  used,  up  to  the  present  time,  it  has 
achieved  no  results  which  entitle  it  to  more  than  a  third  or  a  fourth- 
rate  place  among  remedies;  but  that  if  the  desideratum  of  a  low-tension 
continuous  current,  which  can  be  readily  applied  for  long  periods 
together,  can  be  obtained  by  means  of  apparatus  of  moderate  porta- 
bility and  cheapness,  it  is  probable  that  we  may  obtain  that  which 
will  equal  or  exceed  in  value  any  of  the  remedial  measures  which  are 
at  our  disposal. 

A  few  words  must  be  given  to  the  rather  uninviting  subject  of 
the  surgical  treatment  of  inveterate  Neuralgia.  The  section  of  a 
neuralgic  nerve,  or  rather  the  excision  of  a  piece,  is  still,  I  suppose,  to 
be  reckoned  among  the  measures  which  it  may  be  occasionally  justi- 


NEURALGIA.  165 

fiable  to  employ.  Nothing,  however,  either  in  the  two  cases  of  its  use 
which  I  have  seen,  or  in  the  records  of  similar  operations,  would  lead 
me  to  recommend  it  in  any  case.  The  relief  given  is  nearly  always 
very  transient :  and,  indeed,  the  nearly  infallible  certainty  with  which 
the  pain  returns  in  the  central  end  of  the  divided  nerve  is  only  what 
I  should  expect  from  the  many  considerations  which  point  to  the 
central  origin  of  the  nerve  as  the  most  peccant  part.  With  such 
remedies  in  our  hands  as  the  subcutaneous  injection  of  morphia,  &c. 
I  cannot  see  that  we  need  be  tempted  to  perform  such  an  operation 
for  the  sake  of  a  temporary  alleviation. 

The  removal  of  any  distinct  source  of  peripheral  irritation  by 
surgical  means  is  quite  another  matter,  and  may  be  highly  proper  and 
necessary.  Yet  even  here  it  is  always  necessary  to  calculate  whether 
the  shock  of  the  procedure  itself  may  not  be  injurious;  and  it  will  be 
desirable  before  inflicting  it  to  fortify  the  system,  as  far  as  possible, 
with  tonics;  and  sometimes  to  diminish  the  shock,  not  merely  by 
giving  chloroform,  but  by  prolonging  the  chloroform  narcosis  by  sub- 
cutaneous injection  of  a  large  dose  of  morphia.  This  precaution  is 
especially  advisable  where  we  extract  one  or  more  carious  teeth, 
which  may  seem  to  be  keeping  up  neuralgic  pain.  Too  often  we 
find  that  the  extraction  has  been  in  vain ;  and  then,  unless  some 
such  precautions  have  been  taken,  it  may  be  discovered  that  the 
shock  has  aggravated  the  Neuralgia. 

A  most  important  subject  with  which  I  may  conclude  these 
remarks  on  treatment,  is  the  employment  of  suitable  prophylactic 
measures.  First,  as  regards  nutrition  ;  it  is  absolutely  necessary  that 
this  should  be  as  abundant  as  may  be  possible  without  deranging  the 
digestion.  It  must  also  contain  a  liberal  allowance  of  fatty  matters ; 
no  amount  of  dislike  on  the  patient's  part — and  they  often  show  great 
dislike — should  induce  the  physician  to  give  up  this  point.  If  one 
form  of  fat  cannot  be  tolerated  another  must  be  tried  ;  perseverance 
will,  I  believe,  always  bring  success;  and  the  effect  of  an  improvement 
of  this  kind  in  the  diet  will  rarely  fail  to  tell  upon  the  constitution, 
rendering  the  nervous  system  less  sensitive  to  the  ordinary  exciting 
causes  of  neuralgic  pain.  Equally  important  is  the  avoidance  of 
exposure  to  cold  and  damp  air  with  insufficient  clothing,  for  cold  is 
much  the  most  frequent  immediately  determining  cause  of  neuralgic 
attacks.  Flannel  under-clothing,  thick  veils  for  the  face,  &c.,  are 
quite  as  important  as  any  direct  remedies.  It  cannot  be  doubted 
that  everything  which  tends  to  set  up  the  habit  of  pain,  directly 
tends  also  to  aggravate  that  obscure  vice  of  the  organism  on  which 
the  disposition  of  Neuralgia  depends,  and  vice  versd.  Physical  exercise 
must  be  so  regulated  that  it  may  improve  nutrition  without  inflicting 
severe  fatigue.  And  as  regards  mental  influences,  which,  unfortu- 
nately, are  often  beyond  control,  one  can  only  say  that  the  two 
extremes,  of  a  specially  laborious  and  exciting  life,  and  an  existence 
spent  in  the  dreary  monotony  of  idleness,  are  equally  hurtful. 


In  the  foregoing  article  I  have  followed  the  plan  also  adopted  in  my  article  on 
Alcoholism  ;  namely,  of  stating  my  own  view  of  the  subject  connectedly,  and  without 


166  DISEASES    OF    THE    NEKVES. 

pausing  to  answer  all  the  statements  and  opinions  of  the  numerous  writers  who  differ 
from  me.  The  necessary  limits  of  a  work  like  this  "  System  of  Medicine,"  makes  it 
almost  impracticable  for  an  author  to  follow  any  other  course  with  success,  if  he 
happens  to  hold  a  view  of  his  subject  which  conflicts  with,  or  differs  from,  the  view 
of  well-known  authors  on  a  considerable  number  of  points.  But  the  following 
selected  list  of  the  more  important  treatises  will  enable  the  reader  to  study  the  ques- 
tions connected  with  this  disease  from  every  point  of  view.  It  has  been  my  purpose 
to  bring  out  clearly  and  consistently  that  view  of  Neuralgia  which  seems  warranted 
by  the  majority  of  the  facts  recorded  by  others  or  observed  by  myself  ;  and  the  result 
has  been  that  I  have  given  much  prominence  to  the  arguments  for  the  existence  of 
an  element  of  organic  change  in  the  centres  in  all  true  Neuralgias.  Those  who  desire, 
however,  to  hear  all  the  arguments  which  can  be  urged  for  a  chiefly  or  solely  peri- 
pheral origin  of  Neuralgia  will  find  abundant  material  in  the  undermentioned  treatises  : 
Trousseau,  "  Nfivralgie  Epileptiforme,"  vol.  i.  of  his  "  Clinique  Medicale,"  2me  Edit.  ; 
"  Nevralgies,"  vol.  ii.  of  the  same  work.  (Trousseau's  insistance  on  the  constant  pre- 
sence of  a  painful  "  point  apophysaire,"  seems  to  me  an  overstatement ;  but  it  is  still 
more  strange  that  this  author  should  think  its  constant  presence  could  consist  with 
peripheral  origin  of  Neuralgia.)  Beau,  Traite  des  Nevralgies,  Arch,  de  Med.  1847. 
Brown-Sequard,  Lectures  on  the  Therapeutics  of  Nervous  Diseases,  Lancet,  1866,  vol. 
i.  See  also  his  Lectures  on  the  Physiology  and  Pathology  of  the  Central  Nervous 
System,  8vo.  Philadelphia,  1860.  Of  authors  who  allow  at  least  a  large  share  in  the 
production  of  many  cases  of  Neuralgia  to  the  centres,  are  Teale,  Treatise  on  Neuralgic 
Diseases,  &c.  London,  1829.  C.  Handfield  Jones,  on  Functional  Nervous  Disorders, 
London,  1864  ;  also  Lumleian  Lectures,  Med.  Times  and  Gaz.  1865,  vol.  ii.  But  the 
most  suggestive  and  important  treatise,  and  one  which  has  been  unaccountably 
neglected,  is  the  Observations  on  the  Functional  Affections  of  the  Spinal  Cord,  by 
William  and  Daniel  Griffin,  London,  1834.  I  have,  in  the  text,  given  Valleix  just 
credit  for  laying  the  foundations  of  the  current  knowledge  respecting  Neuralgia  ;  but 
it  must  be  allowed  that  in  the  work  of  the  Griffins,  which  is  little  known,  there  are 
the  germs  of  a  great  improvement  of  that  knowledge.  Of  essays  which  illustrate  the 
serious  secondary  complications  which  may  attend  Neuralgia,  the  following  may  be 
mentioned,  besides  the  treatises  of  Barensprung,  of  Notta,  the  work  of  the  Griffins,  and 
other  papers  already  specified  : — Schiflf,  Hypersemia  of  the  Eye,  Ulceration  of  Cornea, 
&c.  after  a  Wound  of  the  Superior  Maxillary  Nerve  ;  Untersuch,  p.  116.  Allcock, 
Disease  of  the  Eye  from  injury  to  the  Infra-orbital  Nerve.  Todd's  Cyc.  of  Anat.  and 
Physiology,  vol.  ii.  p.  132.  A  great  many  cases  also  are  quoted  in  Handfield  Jones's 
Lectures  on  Functional  Nervous  Disorders,  already  cited. 

It  is  only  just  to  Dr.  Haudfield  Jones  to  acknowledge  that  he  has  long  advocated 
the  opinion  that  nerve-pain  is  invariably,  and  in  all  its  phases  and  consequences,  an 
expression  of  debility  of  function  ;  an  opinion  which  has  been  strongly  expressed 
also  by  myself  not  only  in  the  present  article,  but  in  many  other  papers. 


LOCAL    PAEALYSIS    FROM    NERVE    DISEASE.  167 


V. 
LOCAL  PARALYSIS  FROM  NERVE  DISEASE. 

By  J.  WARBURTON  BEGBIE,  M.D.,  F.R.C.P.E. 

THERE  can  be  no  doubt  that  for  a  lengthened  period,  and  till  a  com- 
paratively recent  date,  the  attention  of  pathologists  was  too  exclusively 
directed  to  the  great  nervous  centres  in  explanation  of  the  causes  of 
nearly  all  nervous  disorders,  including  paralysis.  So  much  so  was 
this  the  case  as  fully  to  justify  the  language  employed  by  the  late  Dr. 
Graves,  of  Dublin.  "  If,"  says  he,  "you  examine  the  works  of  Rostan, 
Lallemand,  Abercrombie,  and  those  who  have  written  on  diseases  of 
the  nervous  system,  you  will  find  that  their  inquiries  consist  in  search- 
ing after  the  causes  of  functional  changes,  either  in  the  cerebrum,  cere- 
bellum, or  spinal  marrow,  forgetting  that  these  causes  may  be  also  resi- 
dent in  the  nervous  cords  themselves  or  their  extremities,  which  I 
shall  call  their  circumferential  tracts."1  Since  1843,  however,  when 
the  first  edition  of  Graves's  lectures  appeared,  it  has  been  satisfactorily 
determined  by  physiological  investigation  and  by  the  careful  observa- 
tion of  disease  in  numerous  examples,  that  paralysis,  or  the  loss  of  the 
power  of  motion,  may  result  from  one  or  other  of  two  causes.  It  may 
depend  either  on  a  central  nervous  lesio>n,  that  is,  a  lesion  of  the  Brain 
or  Spinal  Cord,  or  on  an  abnormal  condition  of  a  particular  nerve  in 
some  part  of  its  course.  It  is  with  the  latter,  as  giving  rise  to  a  local 
form  of  paralysis,  that  we  are  now  exclusively  concerned.  We  are 
abundantly  familiar  with  the  effects  of  mechanical  injury  as  applied 
to  nerves.  When  a  nerve  is  cut  across  there  results  immediately  a 
paralysis  of  the  parts  below  the  section  supplied  by  that  nerve. 
Further,  if  a  nerve  be  included  in  a  ligature,  or  subjected  from  any 
cause  to  much  pressure,  a  similar  result  is  produced.  The  paralysis 
of  the  arm  caused  by  pressure  on  the  axillary  plexus  of  nerves,  is  an 
excellent  and  familiar  illustration  of  injury  so  occasioned.  It  is  thus 
described  by  Dr.  Todd :  "A  man  gets  intoxicated,  and  falls  asleep 
with  his  arm  over  the  back  of  a  chair ;  his  sleep  under  the  influence 
of  his  potations  is  so  heavy,  that  he  is  not  roused  by  any  feelings  of 
pain  or  uneasiness,  and  when  at  length  he  awakes,  perhaps  at  the  ex- 
piration of  some  hours,  he  finds  the  arm  benumbed  and  paralyzed.  It 
generally  happens  that  the  sensibility  is  restored  after  a  short  time, 
but  the  palsy  of  motion  continues.  Cases  of  this  kind  sometimes 

1  Cliuical  Lectures  on  the  Practice  of  Medicine,  Lecture  xxxiii. 


168  DISEASES    OF    THE   NERVES. 

derive  benefit  from  galvanism,  but  if  the  pressure  which  caused  the 
paralysis  has  been  very  long  continued,  they  seldom  come  to  a  favour- 
able termination.  Nerve-tissue  is  one  which  never  regenerates 
quickly,  and  seldom  completely,  so  that  great  or  long  continued 
lesion  of  its  structure  is  not  likely  to  be  removed."1  Although  by  no 
means  so  distinctly  witnessed  as  the  result  is,  in  the  class  of  cases 
now  referred  to,  there  seems  no  reason  to  doubt  that,  equally  with 
mechanical  injury,  interference  with  the  proper  nutrition  of  nerves 
may  lead  to  forms  of  local  palsy.  Illustrations  of  such  occurrences 
will  be  adduced  more  especially  when  directing  attention  to  one  of 
the  most  interesting  of  all  the  varieties  of  local  paralysis,  namely, 
facial  palsy.  Again,  familiar  as  we  are  with  the  action  of  various 
poisons,  such  as  alcohol,  opium,  chloroform,  on  the  great  nervous 
centres,  and  on  the  same  portions  of  the  nervous  system  of  certain 
poisons  formed  in  the  living  body,  as  urea,  and  the  morbid  materials 
in  rheumatism  and  gout;  having  also  important  knowledge  regarding 
the  influence  which  is  exerted  on  the  nervous  and  muscular  systems 
generally,  but  especially  on  the  nerves  and  muscles  of  the  upper  ex- 
tremities by  the  poison  of  lead,  we  cannot  hesitate  to  account,  in  a 
manner  closely  similar,  for  the  other  forms  of  local  paralysis  which 
from  time  to  time  present  themselves  to  our  notice. 

Dr.  Todd  alludes  to  cases  of  local  paralysis  occurring  in  states  of  the 
constitution  which,  if  not  rheumatic,  are  at  least  allied  to  it,  and 
associated  with  imperfect  action  of  the  kidneys.  "  Of  this,"  he  says, 
"  the  following  affords  a  good  example :  A  medical  man,  ffitat.  53,  ex- 
tensively engaged  in  practice  in  the  county  of  Bucks,  applied  to  me  in, 
August,  1847,  with  complete  paralysis  of  the  deltoid  muscle.  He  was 
a  stout,  full  man,  tall,  of  large  build,  and  very  active  in  his  habits; 
fed  well,  and  drank  beer,  but  not  to  excess.  He  had  been  subject  to  a 
shifting  neuralgia  of  the  scalp,  and  to  a  discharge  from  the  right  ear, 
where  he  thought  the  tympanic  membrane  was  destroyed;  he  was  deaf 
on  that  side.  Six  weeks  before  he  came  to  me  he  suffered  from  pain 
in  the  left  side  of  the  neck  and  shoulders,  followed  by  complete 
paralysis  of  the  left  deltoid  muscle  and  weakness  of  the  whole  arm. 
On  examining,  I  found  a  total  inability  to  raise  the  left  arm  to  a  right 
angle  with  the  trunk,  or  to  perform  any  of  those  actions  which  are 
usually  effected  by  the  deltoid  muscle,  which  was  very  much  wasted. 
He  could,  however,  grasp  perfectly  with  the  left  hand,  and  execute  all 
the  other  movements  of  the  arm  and  forearm.  There  was  some  degree 
of  numbness  of  the  arm.  There  were  no  symptoms  distinctly  referable 
to  the  head.  His  tongue  was  coated ;  appetite  good ;  the  discharge 
from  the  ear  had  ceased.  The  urine  was  pale,  of  low  specific  gravity, 
and  contained  albumen  in  small  quantity.  I  viewed  the  case  as  one 
of  local  palsy,  connected  with  a  deranged  state  of  system,  rheumatic 
or  gouty.  I  regulated  his  diet,  and  gave  him  small  doses  of  the  mineral 
acids.  After  a  fortnight  of  this  treatment  he  improved  considerably, 
and  could  raise  his  arm  slightly.  The  albumen  in  the  urine  had  much 

'  Clinical  Lecturea  on  Paralysis,  certain  diseases  of  the  Brain,  and  other  affections  of 
the  Nervous  System,  Lecture  i. 


LOCAL    PARALYSIS    FROM    NERVE    DISEASE.  169 

diminished  ;  and  crystals  of  lithic  acid  were  precipitated.  He  was 
now  ordered  three  grains  of  iodide  of  potassium,  with  ten  minims  of 
liquor  potassa3  thrice  daily.  He  only  followed  this  treatment  for  ten 
days,  as  the  iodide  of  potassium  purged  him.  Still,  he  was  improving, 
I  continued  the  liquor  potassse,  and  advised  galvanism  to  the  muscle. 
This  plan  was  diligently  pursued  for  a  fortnight,  at  the  end  of  which 
time  he  had  so  far  improved  that  he  could  raise  his  arm  nearly 
to  a  right  angle,  he  could  put  on  his  coat,  and  tie  his  cravat ;  and  in 
three  weeks  more  he  was  quite  well.  All  signs  of  albumen  had  dis- 
appeared from  his  urine."1  The  writer's  experience  has  furnished  cases 
bearing  a  remarkable  resemblance  to  the  one  now  quoted.  He  calls  to 
remembrance  more  especially  that  of  a  young  and  plethoric  as  well  as 
highly  rheumatic  female,  who  suffered  from  paralysis,  succeeding  severe 
pains  of  the  left  lower  extremity,  and  in  whom  a  plan  of  treatment 
which  secured  the  copious  discharge  of  urine,  previously  much 
diminished  as  well  as  disordered,  and  free  action  of  the  skin,  proved 
eminently  successful  in  removing  the. palsy  of  the  limb.  Besides  the 
gouty  and  rheumatic  poisons,  it  is  well  to  keep  in  view  the  very  decided 
action  of  the  syphilitic  in  inducing  this  among  other  local  disorders. 
No  one  calls  in  question  the  injurious  effects  which  are  capable  of 
being  produced  on  the  nervous  centres  by  the  syphilitic  poison  ;  there 
is,  however,  good  reason  to  believe  that  some  local  palsies  are  thus 
created.  The  writer  has  been  able  to  trace  the  occurrence  of  paralysis 
of  the  portio-dura,  of  paralysis  of  the  third  pair,  as  shown  by  a  marked 
ptosis ;  and  also  of  palsy  of  the  limbs,  slight  although  threatening,  to 
the  same  cause,  when  neither  brain  nor  spinal  cord  appeared  to  be  im- 
plicated. And  it  is  probable  that  the  experience  of  many  physicians 
has  not  been  dissimilar  to  his  own,  in  finding  the  iodide  of  potassium 
administered  in  large  doses,  and  steadily  persevered  with,  a  most  useful 
remedy  in  such  cases,  relieving  the  palsy  as  effectually,  as  it  is  so  fre- 
quently the  means  of  doing,  the  neuralgic  and  wearing-out  headache, 
or  the  painful  node  on  the  shin-bone,  which  are  evidently  due  to  the 
same  cause.  Allusion  has  been  made  to  the  influence  of  direct  pressure 
external  to  the  body,  in  producing  such  injury  of  nervous  structure  as 
leads  to  a  form  of  local  paralysis.  Palsy  thus  induced  is  generally 
merely  temporary  in  duration.  Tumours  within  the  body,  involving 
nerves,  are  frequently  the  direct  occasion  of  local  palsies.  No  more 
interesting  variety  of  such  palsy  exists  than  that  which  is  due  to  the 
interference  with  the  recurrent  or  motor  laryngeal  nerve  produced  by 
an  aneurism  of  the  arch  of  the  aorta,  or  by  a  cancerous  mediastinal 
tumour.  Well-marked  atrophy  of  the  muscles  of  one  side  of  the 
larynx  has  under  such  circumstances  been  found.  The  dyspnoea,  which 
is  induced  by  the  implication  of  the  vagus,  or  as  sometimes  happens  of 
the  phrenic  nerves  in  strumous  or  tubercular  tumours,  is  abundantly 
recognized  since  the  writings  of  Eisberg  and  Ley.  There  seems  reason 
to  believe  likewise  that  pressure  upon  or  other  injury  of  some  parts  of 
the  sympathetic  nervous  system  may  occasion  local  palsies.  Of  this 
the  paralysis  of  the  radiating  fibres  of  the  iris  caused  by  cutting  the 

1  Loc.  cit.,  p.  72. 


170  DISEASES    OF    THE    NERVES. 

sympathetic  in  the  neck  in  Budge  and  Waller's  experiments,  but 
especially  a  similar  contraction  of  the  pupil  to  that  physiologically 
produced,  due  to  the  pressure  of  aneurism  projecting  into  the  neck 
or  malignant  tumour  similarly  situated,  are  now  quite  familiar  to  the 
physician. 

Attention  will  now  be  directed  to  some  of  the  more  important 
varieties  of  local  palsy  dependent  on  nerve  disease,  and  first  to  Facial 
Palsy.  This  most  interesting  local  paralysis  is  known  under  different 
names,  of  which  the  more  commonly  employed  are  Facial  Hemiplegia, 
Histrionic  Paralysis,  Bell's  Palsy,  and  Paralysis  of  the  Portio-dura. 
Occurring  as  it  usually  does  on  one  side  of  the  face  only,  nothing  can 
be  more  striking  than  the  peculiar  features  of  the  disease.  This  is 
owing  to  the  palsied  condition  of  a  few  or  all  of  the  superficial  mus- 
cles— the  muscles  of  expression — on  the  affected  side,  and  the  height- 
ened antagonism  of  muscular  action  on  the  unaffected  side.  The 
patient  cannot  knit  the  forehead,1  neither  can  the  eyebrows  be  raised 
or  drawn  together.  The  eye  remains  open,  as  the  power  of  closing 
the  lids  is  lost,  and  their  blinking  movement  no  longer  exists.  This 
open  condition  of  the  eye,  seen  both  in  waking  and  sleeping,  and 
which  is  due  rather  to  the  increased  action  of  the  levator  palpebree 
muscle  than  to  the  palsy  of  the  orbicularis  palpebrarum,  is  a  charac- 
teristic, it  has  indeed  been  styled  a  pathognomonic  feature  of  facial 
palsy.3  The  ala  nasi  is  dependent,  and  on  full  inspiration  on  smelling 
or  blowing  the  nostrils  there  is  no  expansive  movement.  The  angle 
of  the  mouth  hangs  down.  Further,  the  patient  cannot  whistle,  for 
he  is  unable  to  purse  up  his  mouth  for  that  purpose,  and  for  the  same 
reason  he  can  neither  spit,  nor  can  he  distend  the  buccal  cavity  with 
air,  or  blow  wind  from  the  mouth.  Pronunciation  of  labials  is  notably 
impaired.  The  saliva  and  fluids  frequently  trickle  from  the  mouth. 
In  mastication  portions  of  food  are  apt  to  collect  between  the  cheek 
and  gurns,  as  the  support  of  the  lips  and  cheeks  necessary  for  its  pro- 
per performance  is  lost.  Let  the  patient  laugh,  cry,  sneeze,  yawn,  or 
be  the  subject  of  any  violent  emotion,  and  the  distortion  of  the  fea- 
tures becomes  much  more  conspicuous,  the  face  being  forcibly  drawn 
to  the  sound  side.  Motionless  and  void  of  expression  is  the  one  side, 
contrasting  in  a  very  remarkable  manner  with  that  on  which  intelli- 
gence remains  visible  and  power  of  movement  unaltered.  Trickling 
of  the  tears  down  the  cheek,  owing  to  the  immobility  of  the  lower 
eyelid,  with  consequent  dryness  of  the  corresponding  nostril,  and  red- 
ness of  the  conjunctiva,  it  may  even  be  severe  conjunctivitis,  deter- 
mined by  the  operation  of  cold,  dust,  or  other  external  influences  on 

1  In  alluding  to  the  smoothness  of  the  brow  in  the  aged,  who  are  affected  by  facial 
palsy,  owing  to  the  disappearance  of  all  wrinkles,  Romberg  facetiously  observes,  "  fur 
alte  Frauen  kein  wirksaineres  Cosmeticum  existirt." 

2  "  The  leading  character  of  cases  of  facial  palsy,"  writes  Dr.  Todd,  "  is  the  inability 
to  close   the  eyelids,  from  paralysis    of  the  orbicularis  palpebrarum ;  this   is    the 
pathognomonic  sign  which  determines  the  peculiar  nature  of  the  palsy,  and  dis- 
tinguishes   it   from  the  most  serious  form    of  facial  palsy,  which  is  dependent   on 
disease  of  the  brain  and  palsy  of  the  fifth  or  third    nerve."     (Clinical    Lectures, 
Lecture  iv.) 


LOCAL    PARALYSIS    FROM    NERVE    DISEASE.  171 

the  constantly  exposed  eye,  are  among  the  accompanying  phenomena 
of  this  palsy. 

To  Sir  Charles  Bell  we  are  indebted  for  pointing  out  the  true 
nature  of  this  affection.  He  showed  that  one  nerve  only  was  invol- 
ved, that  the  muscles  governed  by  the  portio-dura  of  the  seventh 
pair  were  alone  affected,  that  strictly  it  is  a  local  palsy.  The  sensi- 
bility of  the  face  is  usually  unimpaired  ;  a  slight  affection  of  the  fila- 
ments of  the  fifth  may,  however,  cause  a  little  facial  pain,  but  that  is- 
to  be  accounted  rare.  In  instances  of  long  standing  facial  palsy, 
Eomberg  has  drawn  attention  to  the  relaxed  and  flaccid  condition  of 
the  skin  covering  the  affected  muscles,  while  Dr.  Todd  has  insisted  on 
increasing  flaccidity  of  the  cheek,  and  especially  a  rapid  development 
of  that  condition,  as  a  symptom  of  unfavourable  omen  as  regards  the 
patient's  prospects  of  recovery.  But  while  this  form  of  local  palsy  is 
clearly  dependent  on  lesion  of  one  nerve  only,  there  is  reason  to 
believe,  as  Romberg  has  more  particularly  shown,  that  its  features 
are  subject  to  modification,  according  to  the  precise  seat  of  the  disease. 
That  may  be  peripheral  or  central.  Not  only  so,  but  the  diagnostic  marks 
may  vary  under  the  former  head,  according  as  the  superficial  distribu- 
tion of  the  portio  dura,  or  the  nerve  as  it  passes  through  the  temporal 
bone  or  the  nerve  within  the  cranium  and  near  its  central  origin,  is 
affected.  Viewing  these  very  briefly  in  their  order,  it  may  be  re- 
marked— that,  facial  palsy,  due  to  an  affection  of  the  superficial  distribu- 
tion of  the  nerve,  is  generally  met  with  as  the  result  of  exposure  to 
cold.1  "A  very  common  cause  of  this  palsy,"  writes  Dr.  Todd,  "  is 
the  influence  of  cold;  as  by  exposure  at  an  open  window,  in  a  coach 
or  railway  carriage,  to  a  current  of  cold  air."2  "  A  blast  of  cold  air 
on  one  side  of  the  face,"  remarks  Dr.  Graves,  "  has  been  known  to 
cause  paralysis  and  distortion  of  several  months'  duration."3  Exter- 
nal injuries,  such  as  blows  on  the  cheek,  and  surgical  operations  on 
the  face,  have  been  followed  by  this  form  of  local  palsy.  Of  the 
cases  which  occur,  there  are  not  a  few  in  which  no  traumatic  cause 
can  be  found,  neither  can  any  marked  exposure  to  cold  be  traced. 
In  such  circumstances  it  is  proper  to  make  a  very  careful  inquiry  into 
the  condition  of  general  health  of  the  sufferer,  when,  it  is  not  unlikely 
that  the  connection  of  the  palsy  with  a  gouty  or  rheumatic  taint  may 
be  satisfactorily  established.  Dr.  Todd,  alluding  to  the  dependence 
of  periodical  neuralgic  affections  on  the  determination  of  some  poison 
to  a  particular  nerve,  as  the  paludal  poison  or  some  matter  generated 
in  the  system,  expresses  the  opinion  that  morbid  matters  may  affect  a 
motor  nerve  just  as  they  affect  a  sensitive,  causing  in  the  former  case 
paralysis,  as  in  the  latter  they  determine  neuralgia. 

Facial  Palsy  caused  by  an  affection  of  the  portio-dura  in  its  passage 
through  the  temporal  bone, — The  connection  of  this  paralysis  with  local 

1  Some  writers  speak  of  facial  palsy  as  specially  a  disease  of  northern  climates. 
Thus,  Joseph   Frank,  after  alluding  to  the  collection   of  cases  by  various  authors, 
remarks,    "  Nosque  plurima  vidimus.     Morbus  iste  in  regionibus  septentrionalibus 
tarn    cominuuis    est,   ut    spatio    quindecim    annorura    viginti    duo   mihi    obveuerint 
exempla."     (De  Paralysi,  Praxeos  Medicae  Universse  Praecepta.) 

2  Loc.  cit.,  p.  09.  3  Loc.  cit.,  p.  380. 


172  DISEASES    OF    THE    NERVES. 

strumous  affections  in  children  is  well  known.  These  may  be  simple 
and  easily  remediable,  as  for  example  the  parotid  and  more  general 
glandular  enlargements  consequent  on  measles,  scarlatina  and  other 
disorders;  but  of  much  more  serious  nature  is  the  otitis  resulting  in 
caries  of  the  petrous  portion  of  the  temporal  bone.  Here  the  palsy  is 
associated  with  deafness,  and  very  probably  also  with  purulent  dis- 
charge from  the  meatus.  Direct  violence,  likewise,  as  in  a  case  related 
.by  Sir  Charles  Bell,  in  which  a  pistol  shot  through  the  ear  had 
splintered  the  bone,  and  torn  the  nerve  in  its  osseous  canal,  may  of 
course  determine  the  palsy.  The  diagnosis  of  the  disease  or  injury 
affecting  the  nerve,  in  its  passage  through  the  bone,  rests,  according 
to  Komberg,  not  only  on  the  coexistence  of  such  phenomena  as 
otorrhosa,  removal  of  necrosed  portions  of  bone,  perhaps  of  one  or 
other  of  the  small  bones  of  the  ear,  and  deafness — symptoms  which 
are  not  likely  to  occur  in  cases  of  simple  peripheral  facial  palsy,  but 
further,  upon  certain  peculiarities  in  the  observed  paralytic  phenomena. 
One  of  these  is  the  diminution  of  taste  on  the  side  of  the  tongue 
corresponding  to  the  palsy,  another  is  a  unilateral  paralysis  of  the 
velum  palati.  On  the  latter  point  the  statements  of  writers  have 
been  very  contradictory.  Romberg  remarks  that  in  four  patients 
afflicted  with  facial  palsy  he  has  noticed  the  paralyzed  condition  of 
the  velum  palati,  the  uvula,  having  a  slanting  direction,  being  arched 
and  the  tip  pointed  to  the  paralyzed  side.  While  failing  to  offer  any 
explanation  of  the  peculiar  position  of  the  uvula,  Romberg  evidently 
attaches  very  great  importance,  in  a  diagnostic  point  of  view,  to  the 
palsied  condition  of  the  velum,  and  the  marked  curving  of  the  uvula; 
concluding,  from-  their  existence,  that  the  seat  of  the  disease  must  be  in 
the  petrous  portion  of  the  temporal  bone.  And  he  again  emphatically 
repeats  when  the  disease  is  in  the  peripheral  distribution  of  the 
nerve,  the  velum  is  not  affected,  "wovon  ich  mich  in  vielen  Fallen 
uberzeugt  habe."  It  is  the  implication  in  the  diseased  condition,  of 
whatever  nature  that  may  be,  of  the  nervus  petrosus  superficialis 
major,  of  Arnold — which  taking  its  origin  from  the  knee-shaped  bulb 
on  the  trunk  of  the  portio-dura  as  it  lies  in  the  Fallopian  aqueduct, 
and  which  communicates  with  Meckel's  ganglion,  whence  the  muscles 
of  the  palate  derive  their  nerves — that  in  the  view  of  Romberg  causes 
the  displacement  of  the  velum  and  uvula.  Dr.  Todd,  while  admitting 
the  occasional  occurrence  of  this  phenomenon,  combats  the  notion  of 
Romberg,  and  maintains  that  undoubted  instances  of  disease  of  the 
aqueduct,  causing  paralysis  of  the  nerve,  are  met  with,  in  which 
affection  of  the  velum  does  not  exist.  In  his  own  experience  the 
symptom  in  question  was  of  very  rare  occurrence,  and  he  regarded  it 
as  a  coincidence.  Since  the  publication  of  the  views  of  the  authors 
now  referred  to,  the  paralysis  of  the  palate  in  facial  palsy  has  received 
renewed  attention  from  M.  Davaine  and  Dr.  Sanders.  The  former 
recorded  one  case  of  unilateral  paralysis  of  the  palate,  in  connection 
with  facial  palsy  of  right  side,  observed  by  himself,  and  has  com- 
mented on  several  instances  furnished  by  Romberg  and  others.  His 
description  of  the  phenomena  he  observed  is  given  as  follows :  "  The 
velum  palati  is  not  regular;  the  arch  formed  by  the  right  anterior 


LOCAL    PARALYSIS    FROM    NERVE    DISEASE.  173 

pillar  is  less  elevated  than  the  left.  The  posterior  pillar  of  the  same 
side  descends  directly  downwards,  without  being  curved  like  that  of 
the  other  side.  The  uvula  is  bent  like  a  bow ;  its  point  is  directed 
forwards  and  towards  the  paralyzed  side,  while  its  base  is  carried  a 
little  towards  the  sound  side.  The  patient's  voice  is  slightly  nasal."1 
Dr.  Sanders,  in  a  valuable  paper,2  gives  an  interesting  case  of  paralysis 
of  the  velum  in  connection  with  facial  palsy  of  the  right  side,  and 
enters  at  some  length  into  a  consideration  of  the  mechanism  of  the 
deviation  of  the  palate.  Dr.  Sanders  is  satisfied  that  a  partial  hemi- 
plegia  of  the  palate  does  exist  in  connection  with  facial  palsy,  and, 
like  it,  is  dependent  on  affection  of  the  portio-dura.  He  believes  that 
this  form  of  palatal  palsy  consists  in  a  vertical  relaxation  or  lowering 
of  the  corresponding  half  of  the  velum  palati,  with  diminished  height 
and  curvature  of  the  posterior  palatine  arch,  on  the  paralyzed  side, 
and  that  it  is  due  to  paralysis  of  the  levator  palati — that  muscle  and 
the  azygos  uvulad,  also  supplied  by  the  seventh  pair,  being  the  only 
muscles  affected.  -Among  several  conclusions  at  which  Dr.  Sanders 
has  arrived,  the  following  appear  to  be  specially  important:  that  the 
partial  paralysis  of  the  velum  in  facial  palsy,  due  to  implication  of 
the  levator  palati  muscle,  is  by  no  means  so  rare  as  palsy  of  the  velum 
(hitherto  not  accurately  described)  has  been  generally  supposed ;  and 
that  the  prognosis  is  not  necessarily  rendered  more  unfavourable  in 
facial  palsy  when  the  palate  is  implicated. 

The  lesion  in  facial  palsy  may  exist  at  the  cerebral  origin  of  the  seventh 
pair  of  nerves.  We  are  not,  however,  called  upon  to  consider  this 
variety  of  facial  palsy :  suffice  it  to  say,  that  its  existence  may  be 
determined,  and  the  differential  diagnosis,  between  it  and  the  other 
forms — already  briefly  considered — established,  by  the  occurrence, 
sooner  or  later,  of  symptoms  due  to  the  implication  of  other  nerves, 
such  as  deafness,  strabismus,  ptosis,  and  anesthesia.  While,  either  the 
presence  of  inflammatory  products,  or  apoplectic  extravasations  in  the 
vicinity  of  the  pons  Varolii  may  be  the  precise  lesion  which  gives  rise 
to  the  palsy,  the  probability  is  that,  in  such  cases,  a  tumour  of  one 
nature  or  other,  and  subject  to  gradual  extension,  exists. 

The  duration  of  Facial  Palsy  is  subject  to  considerable  variety 
according  to  the  precise  seat  and  nature  of  its  determining  lesion. 
Dr.  Todd  remarks  that  "  it  rarely,  if  ever,  lasts  a  shorter  time  than 
ten  days,  whilst  it  very  often  extends  to  as  many  weeks ;  perhaps 
three  or  four  weeks  rnay  be  assigned  as  an  average  duration  for  the 
non-traumatic  cases;  and  Romberg  warns  us  not  to  expect  its  dura- 
tion to  be  brief.  It  is  in  those  cases  which  have  been  evidently 
connected  with  rheumatism  that  he  has  found  the  paralysis  least  en- 
during.3 

The  writer  has  seen  simple  cases  of  the  disease,  in  so  far  as  their 

1  Gazette  Medicale  de  Paris.     1852. 

2  Edinburgh  Medical  Journal,  August,  1865. 

*  "  Die  Dauer  der  mitnischen  Gre.sichtslaluuung  ist  selten  knrz.  Am  kiirzesten  fand 
ich  sie  bei  der  rheumatischen :  doch  habe  ich  sie  auch  hier  in  giinstigen  Fallen  nur 
selten  unter  seclis  Wocheu  wahrgenommen,  eiumal  sah  ich  die  Heilung  innerhalb 
acht,  ein  auderoial  in  vierzehn  Tagen.'1  p.  664. 


174  DISEASES    OF    THE    NERVES. 

cause  was  concerned,  lasting  a  very  lengthened  period,  many  months, 
and  even  a  year. 

It  is  incumbent  on  the  physician  to  be  very  careful  in  offering  an 
opinion  as  to  the  prognosis  in  cases  of  facial  palsy:  that  must  always 
be  founded  on  a  consideration  of  the  probable  cause.  Those  cases  are 
nearly  certain  to  terminate  favourably  in  which  cold  or  rheumatism 
are  to  be  looked  upon  as  the  determining  agents.  On  the  other  hand, 
when  the  palsy  has  been  due  to  mechanical  injury  the  prognosis 
cannot  be  favourable,  and  this  very  specially  in  those  instances 
where  a  division  of  the  nerve  has  been  caused.  We  cannot  be  too 
careful  in  the  expression  of  our  opinion  in  cases  characterized  by 
nerve  disease  within  the  temporal  bone.  The  records  of  medicine 
contain  reports  of  such,  which  have  given  rise  to  meningeal  inflamma- 
tion, intracranial,  even  cerebral  and  cerebellar  abscess  and  death. 

If  prognosis  is  to  be  guided  by  a  just  consideration  of  the  causes, 
so  also  is  the  treatment  of  facial  palsy  when  amenable  to  cure. 
The  remedial  measures  at  our  disposal  may  be  conveniently  classed 
under  the  heads  of  internal  and  external  agents.  In  the  use  of 
the  former,  regard  should  always  be  had  to  the  diathetic  condition 
of  the  patients,  rheumatic,  gouty,  strumous,  syphilitic,  anasrnic,  or 
suffering  from  the  injurious  influence  of  a  paludal  poison.  We 
are  disposed  to  think  that  this  is  one  of  the  forms  of  local  palsies 
in  which  the  loss  of  power  may  be  due  to  changes  in  nerve  structure 
determined  by  neuritis.  In  such  examples,  and  still  more  so  if  there 
be  reason  to  conclude  that  a  syphilitic  taint  is  in  existence,  iodide  of 
potassium  will  prove  a  most  serviceable  remedy.  We  have  ourselves 
found  it  to  be  so.  The  iodide  should  be  administered  in  doses  of  five 
grains  twice  or  thrice  daily,  simply  dissolved  in  distilled  water.  The 
efficacy  of  the  remedy  is  secured  by  its  being  administered  while  the 
stomach  is  empty,  but  food  may  be  taken  very  shortly  thereafter. 
Should  a  rheumatic  or  gouty  habit  be  found  in  connection  with  the 
palsy,  alkaline  remedies,  colchicum,  and  lemon-juice,  may  exert  a 
beneficial  influence,  and  so  probably  will  quinine  or  arsenic  in  the  not 
unknown  examples  of  the  disease  allied  to  intermittent  fevers.  Mer- 
cury in  the  form  of  blue  pill  has  been  extolled  by  several  practitioners. 
Sir  Thomas  Watson  counsels  the  exhibition  of  mercury  "so  as  just  to 
touch  the  gums,"  adding,  "I  should  always  take  this  precaution,  lest 
any  effusion  of  lymph  should  cause  abiding  pressure  on  the  nerve."1 
Iron  is  likely  to  be  useful  when  an  anaemic  condition  of  the  system 
exists.  The  muriate  of  lime,  the  iodide  of  iron,  and  cod-liver  oil,  are 
available  remedies  when  a  strumous  cachexia  obtains.  The  writer 
can  bear  a  decided  testimony  to  the  therapeutic  value  of  strychnine  as 
an  internal  remedy  in  one  long-existing  instance  of  the  disease,  which 
had  bid  defiance  to  the  more  ordinary  remedies ;  he  cannot,  therefore, 
coincide  in  the  observation  of  Dr.  Todd,  that  "  Strychnine  is  of  no  use 
in  such  cases." 

As  to  external  remedies.  Blisters,  strongly  recommended  by  some 
physicians,  are  discountenanced  by  others,  on  the  ground  that  they 

1  Lectures,  vol.  i.  p.  563. 


LOCAL    PARALYSIS    FROM    XERVE    DISEASE.  175 

sometimes  cause  enlargement  of  the  neighbouring  glands,  which  by 
pressure  may  in  their  turn  injuriously  influence  the  nerve  twigs. 
Local  hot  fomentations  and  the  application  of  leeches  are  very  useful 
remedies  at  an  early  period  of  the  disease,  the  employment  of  the 
latter  being  generally  limited  to  persons  of  full  habit,  and  otherwise 
in  the  enjoyment  of  fair  health.  The  endermical  application  of  strych- 
nine— over  a  blistered  surface — the  use  of  various  stimulating  lini- 
rnents,  and  particularly,  in  the  writer's  opinion,  galvanism,  are  the 
more  approved  remedies  in  cases  which  have  lasted  for  a  little  time. 

Before  concluding  our  notice  of  facial  palsy,  we  must  add  a  few 
remarks  on  the  occasional  occurrence  of  the  disease  on  both  sides  of 
the  face,  and  very  briefly  refer  to  the  statements  of  Dr.  Todd  respect- 
ing the  integrity  of  the  seventh  pair  in  cases  of  cerebral  hemiplegia,  a 
view  which  has  recently  been  ably  controverted  by  Dr.  Sanders. 

Double  Facial  Paralysis. — This  is  unquestionably  a  rare  affection, 
and  especially  rare  when  the  double  palsy  is  solely  dependent  on  nerve 
disease.  Komberg  and  Dr.  Christison1  refer  to  cases  of  what  may  be 
styled  simple  bilateral  paralysis  of  the  face,  while  the  seventeenth 
case  in  Dr.  Todd's  lectures  is  a  very  remarkable  example  of  paralysis 
of  the  portio-dura  on  both  sides  connected  with  affection  of  the 
portio-mollis;  for  the  patient  was  "perfectly  deaf  in  both  ears;"  and 
the  loss  of  function  of  both  branches  of  the  seventh  pair  evidently 
resulted  from  disease  in  the  temporal  bone.  In  addition  to  the  writers 
already  named,  M.  Davaine  has  especially  directed  attention  to  the 
subject  in  a  valuable  memoir,  the  title  of  which  is  given  below,2  and 
to  which  Professor  Gairdner,3  of  Glasgow,  in  giving  an  account  of  a 
very  interesting  case  of  double  facial  palsy,  has  referred.  Dr.  Gairdner 
considered  the  paralysis  to  be  due  to  cold,  and  connected  with  rheuma- 
tism of  the  external  branches  alone;  and  in  the  course  of  his  paper  he 
alludes  to  another  case  of  double  paralysis  of  the  portio-dura  evidently 
connected  with  syphilis.  In  the  latter  case  iodide  of  potassium,  with 
iodide  of  mercury  and  corrosive  sublimate,  were  employed  in  alternate 
doses,  and  the  result  was  an  excellent  recovery.  One  example  of  double 
facial  palsy  has  occurred  under  the  writer's  observation ;  it  was  associ- 
ated with  tubercular  disease  within  the  chest,  and  the  patient,  a  man 
of  thirty  years  of  age,  subsequently  died  of  what  appeared  to  be 
strumous  meningitis.  Unfortunately  an  examination  of  the  body 
after  death  was  not  permitted.  This  is  scarcely  the  opportunity  for 
entering  on  a  consideration  of  the  view  which  was  so  strongly  enter- 
tained and  expressed  by  the  late  Dr.  Todd,  that  the  seventh  nerve 
was  very  rarely  involved  in  facial  palsy  depending  on  cerebral  disease, 
and  that  the  affected  facial  muscles  were  those  governed  by  the  fifth 
pair.  It  will,  however,  tend  to  complete  the  brief  exposition  of  facial 
paralysis  now  given,  if  we  state  in  this  connection,  that  there  is,  in  our 
opinion,  no  reason  to  doubt  that  the  view  taken  by  Dr.  Todd,  and  in 

1  Monthly  Journal  of  Medical  Science,  1850. 

2  Metnoire  sur  la  Paralysie  gonerale  ou  partielle  des  deux  Nerfs  de  la  septieme  paire : 
hi  a  la  Societe  de  Biologie  (Mars,  1852)  par  M.  C.  Davaiue.    See  also  Gazette  Medicale 
de  Paris,  1852. 

8  Clinical  Observations,  Lancet,  May  18, 1861. 


176  DISEASES    OF    THE    NERVES. 

which  several  systematic  writers  in  this  country  have  closely  followed 
him,  is  erroneous,  and  that,  on  the  other  hand,  the  current  doctrine  on 
the  Continent,  and  which  has  been  recently  ably  unfolded  and  extended 
by  Dr.  Sanders,  is  correct,  viz:  "that  in  cerebral  hempilegia,  as  in  peri- 
pheral face  palsy,  it  is  the  motor  seventh  nerve  which  is  affected."1 

Disease  of  other  of  the  motor  cerebral  nerves  than  the  portio-dura 
may  likewise  determine  local  palsies.  A  short  reference  to  such  may 
be  made  here. 

Paralysis  due  to  disease  of  the  third  pair  of  nerves.  (Oculo  motor.) 
Ptosis  or  blepharoplegia,  the  falling  down  of  the  upper  eyelid,  is  the 
notable  feature  of  this  affection.  When  this  is  due  to  a  cause  seated 
within  the  cranium,  such  as  an  inflammatory  exudation,  or  a  tumour, 
it  is  almost  invariably  accompanied  by  palsy  of  those  muscles  of 
the  eyeball,  and  those  fibres  of  the  iris  which  are  likewise  governed 
by  the  motor  oculi.  Hence  in  such  cases,  and  they  are  far  from  being 
uncommon,  external  squint  and  dilatation  of  the  pupil  are  associated 
with  the  ptosis.  Not  only  so,  but  other  adjacent  cerebral  nerves  are 
for  the  most  part  implicated,  while  the  indications  of  the  existence  of 
some  formidable  cerebral  lesion  are  under  such  circumstances  not 
likely  to  be  absent.  On  the  other  hand,  when  the  determining  cause 
of  the  local  paralysis  is  peripheral  in  its  seat,  the  ptosis  exists  alone. 
Bomberg  remarks  that  rheumatism  may  be  the  cause  of  paralyzing 
the  palpebral  branch  of  the  motor  oculi,  although,  not  so  frequently  as 
is  the  case  with  the  facial  nerve ;  and  he  distinctly  states  that  when 
so  induced,  the  ptosis  occurs  without  the  participation  of  the  muscles 
of  the  eyeball,  and  the  contractile  fibres  of  the  iris.2  The  writer 
remembers  to  have  seen  this  dependence  of  ptosis  on  rheumatism 
illustrated  in  the  case  of  a  young  lady,  who  after  having  frequently 
suffered  from  distinct  rheumatic  affections,  became  within  a  limited 
period  the  subject  of  facial  palsy  and  ptosis,  the  immediate  peripheral 
impression  on  both  the  seventh  and  third  nerves  being  evidently  due 
to  severe  cold.  A  complete  and  speedy  recovery  occurred  after  the 
local  application  of  warmth  and  the  use  of  anti-rheumatic  remedies. 
M.  Marchal  de  Calvi  has  directed  attention  to  the  occurrence  of  oculo- 
motor paralysis,  consequent  on  very  severe  tic  of  the  face.  M.  Marchal, 
and  likewise  the  late  M.  Jobert  de  Lamballe,  found  the  muscles  of  the 
eyeball  affected  as  well  as  dilatation  of  the  pupil,  the  vision3  disordered, 
and  insensibility  of  the  conjunctiva  in  this  affection.  Such  cases, 
however,  are  rather  illustrative  of  the  reflex  form  of  paralysis,  our 
knowledge  of  which  has  been  of  late  greatly  increased  by  the  observa- 
tions of  M.  Brown-Se'quard  and  others. 

In  the  same  way  as  peripheral  affection  of  the  oculo  motor  nerve 

1  On  Facial  Herniplegia  and  Paralysis  of  the  Facial  Nerve,  by  Wra.  R.  Sanders,  M.  D. 
Lancet,  1865.  See  on  the  same  subject  Dr.  Hughlings  Jackson  ill  Clinical  Lectures 
and  Reports  of  the  London  Hospital,  1864. 

*  "  Der  rhenmatische  Anlass  paralysirt,  obgleich  nicht  in  solcher  Frequenz  wie  den. 
Facialis,  den  Ramus  palpebralis  des  Oculomotorius  und  hat  eine  einfache  Blepharo- 
plegie  ohne  Theiluahme  der  Augenmuskeln  und  der  contractilen  Irisfasern,  nach  der 
Norm  der  isolirten  Leitung,  zur  Folge."  (AugHnmuskellahrnung.) 

J  Memoire  sur  la  Paralysie  de  la  troisieme  paire  consecutive  a  la  Nevrose  de  la 
cinquieme.  (Archives  Generates  de  Medeciue.  Juillet,  184d.) 


LOCAL    PARALYSIS    FROM    NERVE    DISEASE.  177 

exists,  so  may  local  paralysis  result  from  disease  of  the  fourth  pair 
(trochlear))  and  of  the  sixth  pair  (abducens).  Such  are,  however,  much 
less  frequent  in  their  occurrence,  and  specially  so,  as  Komberg  has 
observed,  that  resulting  from  affection  of  the  abducens.  The  author 
just  named  has  made  reference  to  a  case  seen  by  Dr.  Dahling,  and 
published  by  Stromeyer,  in  which  the  facial  and  abducens  nerves  on 
the  left  side  were  paralyzed  in  consequence  of  a  sudden  cooling  of 
the  heated  face. 

Palsy  of  the  tongue  from  affection  of  the  hypoglossus  nerve  in  its 
distribution  is  of  great  rarity,  offering  a  marked  contrast  to  the  fre- 
quency with  which  a  central  lesion  gives  rise  to  the  same  form  of  local 
palsy. 

The  lesser  branch  of  the  fifth  pair  may  be  the  seat  of  disease,  and 
consequently  give  rise  to  masticatory  palsy.  The  movements  of  the 
face  in  mastication  on  one  or  on  both  sides,  as  the  case  may  be,  are 
thus  arrested  or  impeded.  The  temporal  and  masseter  muscles  are 
readily  recognized  to  be  inactive  ;  and  their  condition  when  the  disease 
is  unilateral  offers  to  the  touch  a  marked  contrast  with  the  firmness  of 
the  same  muscles  on  the  unaffected  side  during  the  process  of  masti- 
cation. This  variety  of  local  palsy,  when  due  to  disease  of  the  nerve, 
is  generally  caused  by  tumour  of  the  dura  mater,  or  disease  of  the 
sphenoid  bone,  or  such  a  morbid  condition  of  the  Casserian  ganglion 
as  compresses  the  nerve  itself. 


178  DISEASES    OF    THE    NERVES. 


VI. 
LOCAL  SPASMS. 

BY  J.  WARBURTON  BEGBIE,  M.D.,  F.R.CP.E. 

THE  term  Spasm  (spasmus,  from  and*,  I  draw)  is  used  to  indicate  the 
sudden  and  involuntary  contraction  of  muscular  fibres,  or  of  muscles. 
Hypercinesis  (v.tep,  in  excess,  xti^oij,  motion)  is  likewise  employed 
in  a  sense  precisely  similar.  This  peculiar  vital  phenomenon  may  be 
general  or  local,  involving  apparently  all,  or  nearly  all,  the  muscles  of 
the  body,  or,  on  the  other  hand,  limited  to  a  few  muscles,  it  may  be  to 
one. 

In  every  occurrence  of  Spasm  there  is  increased  action  of  the  motor 
nerve,  the  result  of  which  is  the  sudden  contraction  of  muscular  fibres, 
the  act  itself  being  wholly  removed  from  the  control  of  the  will.  The 
expressions  clonic  and  tonic  are  used,  the  former  to  denote  a  Spasm 
which  is  characterized  by  rapidly  alternating  contraction  and  relaxa- 
tion of  muscular  fibres,  while  the  latter  implies  the  existence  of  the 
contractions  for  a  certain  time,  and  of  this  condition  rigidity  of  the 
affected  muscles  is  also  an  invariable  feature. 

Attention  is  now  to  be  directed  to  local  as  distinguished  from  general 
or  universal  spasms.  To  the  latter,  the  term  convulsions  is  correctly 
applied. 

Local  Spasm  is  not  necessarily  attended  by  pain,  but  it  generally  is 
so,  and  as  expressive  of  painful  Spasm  we  find  a  suitable  term  in 
cramp  (Saxon  Jcramp).  The  term  cramp  is  most  frequently  applied  to 
painful  muscular  contraction  in  the  extremities,  and  to  the  same 
phenomenon  affecting  the  stomach  or  intestines,  and  also  the  heart. 
Such  pain  as  occurs  in  connection  with  Local  Spasm  is  in  all  proba- 
bility due  to  injury  done  to  the  sensory  nerves  supplying  the  muscle 
during  its  violent  contraction. 

Both  kinds  of  muscular  fibre,  both  orders  of  muscles,  the  voluntary 
and  involuntary,  are  liable  to  be  affected  by  Spasm.  Of  the  former 
the  most  familiar  illustration  is  cramp  in  the  extremities.  Of  the 
latter  are  cardiac  and  intestinal  Spasms.  Komberg  has  pointed  out 
that,  as  a  general  rule,  when  the  muscles  of  animal  life,  those  under 
the  control  of  the  cerebro-spinal  nerves,  are  affected  by  Spasm,  the 
fibres  exhibit  a  uniform  contraction  throughout  their  whole  extent, 
while,  on  the  other  hand,  the  muscles  of  organic  life,  over  which  the 


LOCAL    SPASMS.  179 

sympathetic  system  is  dominant,  when  similarly  affected  manifest 
successive  contractions,  moving  like  waves.1 

It  need  scarcely  be  observed  that,  although  the  abnormal  condition 
now  described  as  Spasm  is  evidenced  by  a  disorder  of  muscular  fibres 
or  muscles,  the  cau.se  of  this  disturbance  is  always  resident  in  the 
nervous  system.  There  is  a  very  important  and  interesting  variety 
in  the  connection  which  subsists  between  the  nervous  stimulus  and 
the  phenomenon  of  muscular  contraction.  The  former  may  be  central, 
that  is,  operating  directly  on  the  great  nervous  centres,  the  brain, 
or  spinal  cord ;  or,  and  in  the  case  of  Local  Spasm  this  is  far  the  more 
frequent,  the  irritation  is  peripheral,  and  consequently  the  induced 
action  is  reflex. 

Our  knowledge  of  the  causes  of  Local  Spasms  is  as  yet  far  from  being 
perfect,  and  in  not  a  few  instances  the  attempt  to  determine  these, 
notwithstanding  the  most  careful  inquiry,  signally  fails.  The  etiology 
of  general  convulsive  disorders  is  indeed  more  advanced,  and  may 
serve  to  elucidate  doubtful  points  in  relation  to  the  more  limited  and 
less  serious  affection. 

The  late  Dr.  Graves  of  Dublin  was  one  of  the  earliest  to  direct 
attention  to  the  frequency  with  which  various  nervous  affections,  of 
which  Spasm  is  one,  and  not  the  least  interesting,  are  dependent  on 
reflected  nervous  irritation.  He  has  graphically  described  the  sudden 
and  complete  relief  afforded  to  a  young  lady  who  had  suffered  most 
severely  from  spasmodic  cough  after  the  discharge  of  a  tapeworm, 
which  had  been  effected  by  a  large  dose  of  oil  of  turpentine  with 
castor  oil.2  The  subject  thus  adverted  to  by  Graves  has  more  recently 
attracted  the  attention  of  several  competent  observers,  more  especially 
of  M.  Davaine  in  France,3  and  Dr.  Heslop4  of  Birmingham.  Their 
statements  show  that  the  presence  of  worms  in  the  intestinal  canal  is 
a  frequent  cause  of  remote  nervous  phenomena,  including  Spasms, 
and  throw  doubt  on  the  assertion  of  Romberg,  that  the  influence  of 
worms  in  producing  convulsions  has  been  formally  over-estimated. 
Again,  a  careful  study  of  the  whole  phenomena  in  that  most  interesting 
disease,  spasmodic  asthma,  has  led  to  the  conclusion  that  the  spasmodic 
affection  in  it,  seated  in  the  smaller  bronchial  tubes,  may  be  induced  by 
an  irritation  of  the  nervous  system,  which  is  either  centric  or  eccentric. 
In  the  former  case  the  irritation  is  in  the  nervous  centres  themselves, 

1  Romberg,  Lehrbuch  der  Nervenkrankheiteu  des  Menschen.  Hypercineses, 
Krampfe. 

8  Clinical  Lectures,  Lecture  xl.,  Bronchitic  Asthma,  Cough. 

3  Traite  des  Entozoaires.     Paris,  1860.     M.  Davaine  remarks:  "Tous  les  organes, 
pour  ainsi  dire,  peuvent  ressentir  1'influence  syinpathique  des  vers  du  canal  intesti- 
nal :  la  fausse  perception  des  odeurs,  la  dilatation  de  la  pupille,  1'amaurose  perma- 
nente  ou  passagere,  1'exaltation  de  1'oui'e,  la  perversion  du  gout,  le  prurit  et  les  four- 
millenients  a  la  peau  teinoignent  de  Faction    sympathique    des  vers  sur  les   sens  ; 
d'un  autre  cots',  la  somnolence  ou  les  vertiges,  les  rSves  facheux,  les  spasmes,  les  dou- 
leurs  vagues,  la  toux,  la  dyspnee,  les  palpitations,  les  intermitteucesdu  pouls,  la  faiin 
insatiable  ou  1'auorexie,  la  salivation,  la  qualitS  des  urines,  1'ainaigrissement  temoig- 
nent egalement  de  leur  action  sur  le  systeme  nerveux,  sur  les  organes  de  la  respira- 
tion, de  la  circulation,  de  la  digestion,  sur  les  secretions,  entin  sur  la  nutrition." — 
Page  48. 

4  The  Cerebro-spinal  Symptomatology  of  Worms,  especially  Tapeworms.      Dublin 
Quarterly  Journal  of  Medical  Science,  vol.  xxvii.     1859. 


180  DISEASES    OF    THE    XERVES. 

the  brain,  or  spinal  cord.  In  the  latter,  and  it  is  by  far  the  more 
common  in  its  occurrence,  the  irritation  is  applied  at  a  distance  from 
the  nervous  centres.  This  subject  has  been  very  fully  and  ably  illus- 
trated by  Dr.  Hyde  Salter,  in  whose  work  examples  the  most  interest- 
ing and  conclusive  as  to  the  essentially  nervous  origin  of  the  asthma 
are  to  be  found.1 

In  treating  of  what  may  be  styled  central  asthma,  Dr.  Salter  gives, 
among  others,  the  following  case :  A  man  about  fifty  was  subject  to 
epilepsy.  His  fits  had  certain  well-known  premonitory  symptoms, 
and  occurred  with  tolerable  regularity  about  once  a  fortnight.  On 
one  occasion  his  medical  attendant  was  sent  for  in  haste,  and  found 
him  suffering  from  violent  asthma.  The  account  given  by  his  friends 
was,  that  at  the  usual  time  at  which  he  expected  the  fit  he  had 
experienced  the  accustomed  premonitory  symptoms,  but  instead  of 
their  being  followed  as  usual  by  the  convulsions,  this  violent  dys- 
pnoea had  come  on.  "Within  a  few  hours  the  dyspnoea  went  off  and 
left  him  as  well  as  usual.  At  the  expiration  of  the  accustomed 
interval  after  this  attack,  the  usual  premonitory  symptoms  and  the 
usual  epileptic  tit  occurred.  On  several  occasions  this  was  repeated, 
the  epileptic  seizure  being  as  it  were  supplanted  by  the  asthmatic. 
Nothing  seemed  to  be  amiss  with  the  lungs  either  before  or  after  the 
attack.  Dr.  Salter  truly  observes,  that  such  a  case  as  this  appears  to 
admit  of  only  one  interpretation,  that  the  particular  state  of  the 
nervous  centres  that  ordinarily  threw  the  patient  at  certain  times 
into  the  epileptic  condition,  on  certain  other  occasions,  from  some 
unknown  cause,  gave  rise  to  bronchial  spasm;  that  the  essential 
diseased  condition  was  one  and  the  same,  but  that  its  manifestation 
was  altered,  temporary  exaltation  and  perversion  of  the  innervation  of 
the  lungs  in  the  asthmatic  paroxysm  supplanting  unconsciousness 
and  clonic  convulsion  in  the  epileptic  seizure.  It  has  occurred  to  the 
writer  to  witness  in  one  instance  an  alternation  of  phenomena  bearing 
a  close  resemblance  to  that  observed  by  Dr.  Salter.  The  patient,  a 
young  man,  was  admitted  to  the  Royal  Infirmary  of  Edinburgh,  on 
the  recommendation  of  Dr.  Turner,  of  Keith.  He  had  for  several 
months  previously  been  subject  to  cerebral  attacks,  attended  by  loss 
of  consciousness,  and  occasionally  by  convulsive  movements  of  the 
muscles  of  the  face  and  extremities.  These  continued  to  occur  during 
the  patient's  residence  in  the  hospital,  observing  for  a  time  the  same 
periodicity  which  had  antecedent  to  that  time  always  distinguished 
them,  when,  on  three  separate  occasions,  and  in  the  most  distinct 
manner,  an  attack  of  asthma  took  the  place  of  the  more  manifest 
cerebral  disorder.  The  loss  of  consciousness  and  convulsive  move- 
ments again  recurred  in  a  modified  form :  and  after  the  lapse  of  seve- 
ral weeks,  during  which  various  remedies  were  employed,  the  patient 
left  the  Infirmary  to  return  home,  his  condition  having  materially 
improved.  Besides  instances  of  the  nature  just  alluded  to,  there  are 
other  examples  of  asthma,  which,  although  in  by  no  means  so  distinct 
a  manner,  must  be  held  as  caused  by  some  impression  taking  origin 
in  the  nervous  centres,  and  responding  in  a  mysterious  manner  with 

1  On  Asthma:  its  Pathology  and  Treatment.     London,  1860. 


LOCAL    SPASMS.  181 

certain  feelings  or  emotions  of  the  mind ;  such  are  the  cases  in  which 
fear,  excitment,  and  fatigue  operate. 

Now,  passing  to  a  very  brief  consideration  of  bronchial  Spasm, 
dependent  not  on  centric  but  peripheral  irritation.  Dr.  Salter  speaks 
of  three  degrees  of  remoteness  of  the  application  of  the  stimulus 
producing  asthma,  and  consequently  of  three  groups  into  which  the 
reflex  cases  of  the  disease  may  be  divided  :  1st.  Those  in  which  the 
source  of  irritation  is  alimentary,  and  chiefly  gastric.  2d.  In  which 
the  irritation  is  more  remote,  but  still  confined  to  the  organic  system 
of  nerves,  as,  for  example,  asthma  produced  by  a  loaded  rectum,  by 
the  presence  of  tapeworm,  or  ascarides.  3d.  Cases  in  which  the 
cerebro-spinal  system  is  the  recipient  of  whatever  irritation  is  the 
cause  provocative  of  the  attack,  as,  for  example,  was  illustrated  in  a 
most  remarkable  instance  recorded  by  Dr.  Chowne,  where  the  appli- 
cation of  cold  to  the  instep  produced  in  the  most  direct  manner  the 
asthmatic  paroxysm.  Looking  to  the  first,  and  by  a  long  way  the 
largest,  of  these  three  classes  of  cases,  the  nerve  irritated  is  the  gastric 
portion  of  the  pneumogastric ;  through  it  the  stimulus  reaches  the 
medulla  oblongata,  and  from  that  portion  of  the  nervous  centre  it  is 
again  transmitted  to  the  bronchia  by  the  pulmonary  filaments  of  the 
same  nerve.  It  is  indeed  of  the  highest  importance  in  a  therapeutical 
point  of  view  to  notice  this  chain  of  connection.  We  are  thus  called 
to  recognize  in  the  paroxysm  of  asthma  a  disease  not  unfrequently 
originating  in  disorder  of  the  stomach;  and.  it  may  be  assumed  as 
a  correct  conclusion,  that  a  large  proportion  of  the  sufferers  from  this 
severe  spasmodic  affection  are  to  be  relieved  by  attention  being  given 
to  their  diet  and  regimen.  But  even  here  we  should  be  adopting  too 
limited  a  notion  of  the  influence  of  the  digestive  and  assimilating 
processes  in  the  production  of  asthma  did  we  conclude  that  those 
cases  alone  are  examples  of  this  nature,  in  which  bronchial  spasm  is 
induced  by  reflex  stimulation  directly  through  the  important  nervous 
trunk — the  pneumogastric.  There  are  over  and  above,  numerous 
instances  in  which  this  direct  communication  of  the,  influence  exerted 
will  not  apply.  In  such  the  occurrence  of  the  Local  Spasm  does  not 
so  speedily  follow  the  introduction  of  food  into  the  stomach  as  in 
many  of  the  former  cases,  and  therefore  we  must  look  for  a  somewhat 
different  explanation.  We  find  it  in  the  disordered  condition  of  the 
blood ;  the  faulty  assimilation  is  no  doubt  the  primary  cause  of  this, 
but  the  unhealthy  blood  is  in  such  instances  the  direct  irritant;  by 
its  operation  on  the  nervous  distribution  through  the  lungs  the 
bronchial  Spasm  is  caused.  This  humoral  origin  of  asthma  affords 
in  all  probability  the  most  satisfactory  explanation  of  the  frequent 
occurrence  of  the  nervous  disorder  in  persons  who  are  gouty.  The 
accuracy  of  the  view  thus  expressed  is  further  evidenced  by  the 
circumstance  that  such  sufferers  are  benefited  by  a  plan  of  treatment 
which  tends  to  eliminate  the  essential  poison  of  gout  from  the  system; 
often,  indeed,  are  benefited  by  such  a  plan  of  treatment  only.  In 
these  cases  remedies  need  scarcely  be  directed  to  the  chest :  it  may  be 
possible  to  relieve,  it  is  impossible  to  subdue,  by  antispasmodics,  a 
bronchial  spasm  so  induced ;  but  on  the  other  hand,  by  acting  freely 


182  DISEASES    OF    THE    NERVES. 

on  the  great  emnnctories  of  the  body,  on  the  skin  and  kidneys,  the 
disease  is  to  be  met  and  overcome.1 

Allusion  has  been  made  to  the  production  of  bronchial  Spasm  as 
determined  by  reflex  irritation,  and  also  by  an  impure  condition  of 
the  blood.  The  same  precisely  holds  true  of  cardiac  Spasm.  The 
irregular,  unrhythmical,  and  painful  contractions  of  the  heart  known 
under  the  name  of  palpitation,  are  found  in  close  connection  with 
various  derangements  of  the  general  health  and  of  special  organs. 
Among  the  latter,  those  of  the  alimentary  canal,  but  particularly  of 
the  stomach  and  the  uterus,  occupy  the  chief  place.  Perhaps  the 
most  painful  of  all  the  forms  of  cardiac  palpitation  is  that  resulting 
from  either  an  imperfect  depuration  of  the  blood,  or  from  a  regular 
blood  impoverishment,  or  anasmia,  as  is  so  frequently  observed  in  cases 
of  amenorrhcea  and  chlorosis. 

We  pass  to  a  brief  consideration  of  Spasm  as  occurring  in  the 
muscular  organs  which  constitute  the  alimentary  canal.  It  affects  the 
stomach  and  intestines  as  well  as  the  oesophagus  and  pharynx,  while  the 
severe  pain  determined  by  its  occurrence  in  any  part  of  the  alimen 
tary  tract  is  very  generally  accompanied  by  other  and  various  symp- 
toms which  cannot  with  any  propriety  be  referred  to  now.  Painful 
peristaltic  spasm  of  the  intestines  is  usually  known  under  the  name  of 
colic.  During  its  occurrence,  and  as  affording  proof  of  its  occasional 
violence,  intussusceptio  and  prolapsus  of  the  rectum  may  take  place. 
Foremost  among  the  Determining  causes  of  colic  is  to  be  placed  the 
presence  of  indigestible  articles  of  food  and  morbidly  altered  secre- 
tions in  the  intestinal  canal.  But,  besides  this,  the  influence  of  the 
emotions,  and  more  especially  of  fear  and  fright,  is  well  known ; 
while  just  as  bronchial  Spasm  may  be  due  to  reflex  nervous  irritation, 
so  may  intestinal  spasmodic  stricture,  as  it  is  called,  to  distinguish  a 
temporary  and  functional  from  an  enduring  and  organic  contraction, 
similarly  produced,  have  its  seat  in  any  part  of  the  alimentary  canal. 
In  some  instances  the  direct  exciting  cause  is  seated  at  a  great  dis- 
tance from  the  induced  disorder :  of  this  nature  no  more  common  or 
manifest  example  can  be  given  than  that  of  colic,  often  very  severe, 
resulting  from  the  exposure  of  the  lower  extremities,  it  may  be  of 
the  feet  only,  to  cold  and  damp.  Spasm  of  the  pharynx  and  oesophagus 
is  one  of  the  most  interesting  of  all  the  varieties  of  Local  Spasms. 
It  is  of  common  occurrence,  particularly  in  females,  in  whom  it 
shows  itself  either  as  a  reflex  phenomenon  dependent  on  uterine 

1  Laeimec,  who,  while  strongly  insisting  on  the  connection  between  asthma  (asthme 
spasmodique)  and  catarrh,  admitted  the  existence  of  a  purely  nervous  asthma  (sans 
aucune  complication  de  catarrhe),  has  acknowledged  the  great  difficulty  there  is  in 
the  satisfactory  treatment  of  the  disease.  "  Beaucoup  de  moyens,"  he  remarks, 
"  peuvent  etre  opposes  aux  troubles  de  1'inflnence  nerveuse  qui  constituent  princi- 
palement  1'asthme  :  mais  id,  comme  dans  toutes  les  affections  nerveuses,  rien  n'est  si 
variable  que  1'action  des  medicaments  ;  les  remedes  qui  renssissent  le  mieux  chez  un 
grand  nonibre  de  sujets  sont  sans  efficacit6  pour  beaucoup  d'autres  ;  et  chez  le  mfiine 
individu  tel  moyen  qui  avail  produit  d'abord  des  effets  heroiques,  et  d'une  promptitude 
surpreuante  devient  tout  &  fait  inefficace  au  bout  d'un  petit  nombre  de  jours.  II  faut 
successivement  en  essayer  plusieurs,  et  souvent  de  tres-disparates  :  nous  allons,  eu. 
consequence  parcourir  les  diverses  series  de  inoyens  dont  on  a  tire  le  plus  d'avan- 
tage  dans  Pasthine." — TraiUde  I' Auscultation  Mediate,  Affections  Nerveuses  du  Poumon. 


LOCAL    SPASMS.  183 

irritation,  or — and  this  still  more  frequently  —  as  one  of  the  most 
striking  features  in  a  paroxysm  of  hysteria.  It  is  not  always  an 
easy  task  to  distinguish  between  Spasm  of  the  oesophagus  due  to 
organic  disease  and  that  which  is  simply  the  result  of  a  nervous  irri- 
tation. The  cautious  introduction  of  the  probang  or  oesophageal 
bougie  is  the  most  ready  and  certain  means  for  establishing  the 
diagnosis. 

An  irritation  of  the  pharynx  or  oesophagus,  of  the  stomach,  bowels, 
or  liver,  is  sometimes  the  direct  cause  of  hiccup  or  singultus,  a  spas- 
modic affection  extremely  interesting  in  its  nature.  Sudden  power- 
ful jerking  inspirations,  accompanied  by  a  peculiar  noise,  and  suc- 
ceeded by  a  brief  expiration,  interrupting  speech,  distinguish  hic- 
cup. It  is  essentially  a  reflex  phenomenon  ;  in  the  vast  majority  of 
instances  depending  on  some  peripheral  irritation,  but  occasionally, 
as  its  presence  in  apoplexy,  meningitis,  and  hydrocephalus  testifies, 
determined  by  a  central  cause.  There  seems  to  be  some  difficulty  in 
accounting  for  the  occurrence  of  hiccup  from  an  irritation  of  the 
phrenic  nerve,  as  has  been  suggested  by  various  writers  ;  nevertheless 
it  is  consistent  with  the  writer's  observation  in  several  instance?  of 
long-continued  and  distressing  hiccup,  that  firm  pressure  exerted  for 
a  brief  period  over  the  lower  part  of  the  neck,  corresponding  to  the 
situation  of  the  scaleni  muscles,  so  as  probably  to  compress  the 
phrenic,  has  led  to  its  temporary  and  even  entire  arrestment.  In 
singultus  and  in  yawning,  which  resembles  it  in  being  of  the  nature 
of  inspiratory  convulsion — also  in  sternutatio  or  sneezing,  where  the 
expiratory  function  is  involved — what  is  of  consequence  to  notice  is, 
as  Eomberg  has  pointed  out,  that  the  spasmodic  action  does  not  affect 
a  single  muscle,  but,  on  the  contrary,  groups  of  muscles;  and  that 
these  Local  Spasms,  more  particularly  the  former  hiccup,  while  occur- 
ring as  independent  affections,  are  still  more  prone  to  assume  the 
symptomatic  character;  affording  evidence  of  the  existence  of  some 
other  malady,  or  distant  irritation.1 

Spasm  of  the  urinary  bladder  and  of  the  urethra — what  is  commonly 
sty-led  spasmodic  stricture — are  familiar  to  the  surgeon.  Vesical 
Spasm  is  not  un frequently  a  truly  reflex  phenomenon  :  this  is  wit- 
nessed on  the  introduction  of  the  catheter  or  bougie,  when  violent  and 
'  most  painful  efforts  are  made  to  evacuate  the  organ,  even  when  at 
the  time  empty.  Romberg  insists  on  the  action  of  the  muscles  being 
due  to  an  irritation  of  the  neck  of  the  bladder,  that  particular  part 
being,  as  Sir  Charles  Bell  demonstrated,  the  most  vascular  and  the 
most  sensitive  portion  of  the  viscus.  It  is  when  the  catheter  reaches, 
or  the  calculus  touches,  the  neck  of  the  bladder,  that  the  ischuria  is 
produced  :  and  the  intense  pain  is  seen  to  subside  whenever  the  irri- 
tating body  is  removed  from  that  particular  portion  of  the  organ. 
The  irritation  upon  which  vesical  Spasm  depends  may,  as  we  have 
seen  to  hold  true  of  other  forms  of  Local  Spasm,  be  distant  from  the 

1  "  Hiiufiger  als  auf  einzelne  Nervenbahnen  bescbrankt,  kommen  die  krampf- 
haften  Athembewegungen  zu  Gruppeii  associirt  vor,  entweder  selbstiindig,  oder 
was  ofter  der  Fall  ist,  ablilngig,  uud  in  Begleitung  vou  auderu  Affeotioueu."  (Loc. 
cit.,  p.  35-i.J 


184  DISEASES    OF    THE    NERVES. 

induced  phenomenon.  It  may  be  resident  in  the  kidneys,  or  in  any 
part  of  the  intestinal  canal,  but  very  specially  in  the  rectum.  Hemor- 
rhoids are  a  frequent  cause  of  vesical  Spasm ;  and  it  is  well  known 
in  how  distressingly  severe  a  degree  that  is  apt  to  occur  after  the 
operation  of  their  deligation.  Exposure  of  the  surface  of  the  body, 
especially  of  the  feet,  to  cold  and  wet,  and  depressing  mental  emotions, 
act  in  the  same  way. 

As  our  object  in  this  article  has  been,  not  to  illustrate  every 
example  of  Local  Spasm,  but  rather  to  indicate  the  nature  of  this 
special  morbid  action  by  a  brief  consideration  of  some  of  its  more 
important  and  most  frequently  occurring  varieties,  we  shall  now  take 
a  very  rapid  survey  of  a  few  other  forms,  and  bring  our  remarks  to 
a  conclusion  by  offering  some  general  observations  with  a  special 
reference  to  treatment.  There  is  a  peculiar  variety  of  Local  Spasm 
affecting  certain  muscles  of  the  face,  and  giving  while  it  lasts  a  very 
strange  aspect  to  the  individual.  In  the  histrionic  Spasm  of  the  face, 
by  which  title  this  affection  is  known,  there  are,  in  the  language  of 
Eomberg,  "  grimaces,  alternating  or  lasting,  on  one  side,  seldom  on 
both  sides,  of  the  face."1  Pain  is  occasionally,  but  by  no  means 
necessarily,  an  accompaniment  of  the  disordered  muscular  action. 
A  local  malady  essentially,  because  affecting  the  muscles  governed 
by  one  nerve,  the  seat  of  the  Spasm  is  in  some  instances  still  further 
localized  by  there  only  being  one  of  the  branches  of  the  seventh  pair 
involved.  Of  the  latter  are  blepharospasmus,  or  Spasm  of  the  eyelids, 
and  the  risus  caninus.  The  peculiar  convulsive  grin  thus  named  is 
caused  when  the  molar  and  labial  branches  are  affected.  To  it  the 
terms  spasmus  cynicus  and  sardonic  laugh  are  likewise  applied.  The 
relation  of  facial  Spasm  to  chorea  must  not  be  overlooked ;  this 
association  has  been  frequently  noticed :  and  it  is  also  a  matter  of  not 
unfrequent  observation  that  the  Local  Spasm  lasts  in  some  cases  for 
a  considerable  period  after  the  disappearance  of  the  general  nervous 
disorder  with  which  it  had  been  in  the  first  instance  connected. 

Masticatory  Spasm  is  witnessed  in  its  most  formidable  degree  when, 
as  trismus,  it  accompanies,  or  is  itself  the  chief  element  in,  tetanic 
convulsions.  In  a  much  milder  degree  Spasm  in  the  muscles  which 
are  supplied  by  the  motor  division  of  the  fifth  pair  is  seen  as  a  reflex 
action,  determined,  as  in  children,  by  the  presence  of  worms  in  the 
intestinal  canal,  or  by  the  progress  of  dentition.  The  Spasm  of  the 
muscles  is  sometimes  associated  with  a  grinding  of  the  teeth.  To  the 
occurrence  of  the  latter  symptom  in  persons  of  the  gouty  diathesis 
attention  was  called  by  the  late  Dr.  Graves.  Such  grinding  of  the 
teeth  continued  for  years  as  a  daily  habit,  and  produced  very  re- 
markable changes  in  the  conformation  of  these  organs,  affecting 
sometimes  one  side  of  the  jaw,  sometimes  both  ;  so  that  in  confirmed 
cases  the  teeth  were  frequently  found  ground  down  to  the  level  of  the 
gums.2 

Spasm  of  the  muscles  of  the  eye,  dependent  on  an  irritation  of  the 

1  Loc.  cit.  "Mimischer  Gesichtskrainpf. " 

2  Clin.  Med.,  "Gout." 


LOCAL    SPASMS.  185 

third,  fourth,  or  sixth  nerves,  is  seen  in  strabismus — which  is  to  be 
distinguished  from  the  paralytic  form  by  the  movement  of  the  eyeball 
in  other  directions  being  in  the  former  case  possible — and  in  nystag- 
mus. These  spasmodic  affections  equally  with  others  acknowledge  a 
peripheral  or  central  origin.  Both  are  of  common  occurrence  in 
connection  with  intestinal  and  dental  disorders,  but  they  are  also  not 
unfrequently  the  indications,  sometimes  among  the  very  earliest,  of 
mischief,  inflammatory  or  otherwise,  commencing  at  the  base  of  the 
brain. 

Painful  Spasms  of  the  muscles  of  the  extremities  are  of  very  fre- 
quent occurrence;  and  with  this  affection,  more  especially  seated  in 
the  lower  limbs,  and  there  in  the  calves,  we  are  especially  familiar 
under  the  name  of  cramp.  The  attack  of  cramp  is  usually  sudden  ; 
and  it  frequently  occurs  at  night,  the  person  in  bed  being  awakened 
from  sleep  by  the  seizure.  During  its  continuance  the  muscular  fibres 
are  gathered  up  into  a  hard  knot,  which  is  always  easily  felt  by  touch, 
and  may  often  be  seen.  The  pain  is  very  severe,  and  produces  a 
feeling  of  sickness  and  depression,  which  may  even  lead  to  syncope. 
The  patient  not  unfrequently  gives  utterance  to  an  irrepressible  ex- 
clamation or  scream.  Cramp  usually  lasts  only  for  a  few  moments  ; 
it  may,  however,  continue  for  minutes,  and  even  hours.  A  sudden 
cessation  of  the  Spasm  may  occur,  or  a  more  gradual  relaxation  of 
the  muscular  fibres  ensue;  but  in  either  case,  if  the  attack  have  been 
at  all  severe,  sufficient  injury  during  its  continuance  has  resulted  to 
the  sensory  nervous  filaments  as  to  cause  a  feeling  of  soreness,  always 
increased  by  touch,  and  frequently  an  inability  fully  to  exert  the 
affected  limb  or  other  part  for  some  time.  The  irritation  of  the  sciatic 
nerve,  upon  which  .the  painful  Spasm  of  the  muscles  of  the  calf  de- 
pends, is  intimately  connected  with  disorder  of  the  stomach  and  bowels, 
and  is  also  particularly  prone  to  occur  in  persons  of  the  gouty  and 
rheumatic  habits. 

In  Asiatic  cholera  the  occurrence  of  intensely  painful  cramps  con- 
tributes, as  is  well  known,  largely  to  the  sufferings  of  its  victims. 
Again,  in  persons  of  intemperate  habits  there  is  sometimes  observed 
a  tendency  to  the  development  of  severe  spasmodic  action  in  the 
muscles,  of  the  extremities  more  especially,  but  likewise  of  other 
parts  of  the  body.  In  one  instance  which  fell  under  the  writer's 
observation  a  patient,  having  recently  recovered  from  an  attack  of 
delirium  tremens,  was  seized  with  most  violent  and  painful  Spasm  of 
the  muscles  of  both  upper  and  lower  extremities,  during  which  the 
fingers  were  powerfully  flexed  and  bent  inwards  on  the  palms  of  the 
hands,  as  in  the  carpal  contractions  of  children.  So  severe  was  this 
case,  that  a  syncopal  depression,  very  threatening  in  its  character, 
occurred.  After  lasting  for  several  hours,  and  exhibiting  for  many 
days  a  marked  tendency  to  recur,  the  affection  passed  off,  and  the 
patient  entirely  recovered  both  health  and  strength. 

In  the  treatment  of  local,  as  of  general,  Spasms,  the  great  object  is  to 

remove  the  cause  on  which  they  depend.     In  the  brief  consideration 

of  the  different  varieties  of  Local  Spasm  now  offered  it  has  been  shown 

that  in   a  large  proportion  of  cases  the  excited  muscular  action  is 

12 


186        '  DISEASES    OF    THE    NERVES. 

induced  by  reflex  action;  that  the  direct  exciting  cause  is  a  distant 
nervous  irritation.  Fortunately  the  removal,  or  at  all  events  the 
lessening,  of  this  irritation  is  in  many  instances  within  the  power  of 
our  art.  Again,  in  those  cases,  of  the  frequent  occurrence  of  which 
proof  has  been  afforded,  which  are  characterized  by  a  morbid  state  of 
the  blood,  e.g.,  gouty  or  rheumatic,  we  may  often  be  successful  in  our 
treatment  by  paying  due  attention  to  the  therapeutical  indications — in 
other  words,  by  the  employment  of  an  alterative  or  eliminating  plan, 
suggested  by  the  peculiarity  of  each  individual  case.  We  may  as 
effectually  subdue  the  morbid  action  of  Spasm  as  we  are  constantly 
enabled,  by  the  use  of  suitable  remedies,  to  relieve  that  of  pain  in 
neuralgia.  In  addition  we  possess  in  various  agents  a  power  of  con-' 
trolling  or  completely  removing  such  excited  nervous  action  as  induces 
Local  Spasm :  not  indeed  one  upon  which  we  can  invariably  rely, 
because  we  are  often  disappointed  in  the  results ;  nevertheless  the 
remarkable  therapeutical  effects  which  succeed  the  exhibition  of 
various  of  the  antispasmodic  and  calmative  remedies  is  such  as  to  con- 
vince us  of  their  efficiency.  Our  knowledge,  moreover,  regarding  the 
action  of  such  remedies  is  on  the  increase.  It  is  only  quite  recently 
that  a  valuable  addition  has  been  made  in  the  bromide  of  potassium, 
the  operation  of  which  in  removing  the  painful  cramps  of  cholera,  not 
less  thafa  in  many  instances  averting  the  convulsive  seizure  of  epilepsy, 
has  been  witnessed  by  numerous  observers.1 

Pressure  firmly  exerted  on  the  thigh  relieves  a  violent  cramp  of  the 
calf,  while,  according  to  Dr.  Wise,  the  application  of  a  tourniquet  so  as 
to  compress  the  bloodvessels  will  banish  the  exhausting  muscular  con- 
tractions in  cholera. 

Finally,  in  the  treatment  of  such  exalted  nervous  action  as  deter- 
mines Local  Spasm,  as  in  the  proper  management  of  every  form  of 
derangement  of  the  nervous  system,  however  slight  or  severe,  let  the 
potent  influence  of  peculiarity  in  psychical  constitution,  and  of  the 
ready  susceptibility  in  some  to  the  operation  of  all  manner  of  external 
impressions,  not  be  lost  sight  of. 

1  See  Note  on  the  Therapeutical  Effects  of  Bromide»of  Potassium  by  James  Begbie, 
M.D.,  Edin.  Med.  Journ.  1866.  Also,  The  Action  of  Brouiide  of  Potassium  upon  the 
Nervous  System,  by  J.  Crichton  Browne,  M.D.,  Ibid.  1865. 


TORTICOLLIS.  187 


VII. 
TORTICOLLIS. 

BY  J.  RUSSELL  REYNOLDS,  M.D.,  F.R.C.P. 

DEFINITION. — A  spasmodic  condition  of  the  muscles  of  the  neck — 
generally  clonic,  but  rarely  tonic — whereby  the  head  is  displaced  to 
one  side,  or  towards  one  shoulder;  occurring  almost  exclusively  in 
adult  life,  and  characterized  by  great  obstinacy  and  chronicity. 

SYNONYMS. — Wry-neck ;  spasmodic  wry-neck ;  spasm  in  the  mus- 
cular distribution  of  nervus  accessorius  Willisii,  and  of  the  superior 
cervical  nerve  (Romberg).1 

CAUSES. — So  far  as  I  have  seen,  the  male  sex  has  been  slightly  more 
frequently  affected  than  the  female  ;  but  the  difference  is  so  small,  that 
its  existence  is  of  no  diagnostic  value.  With  only  one  exception,  all 
the  cases  that  I  have  seen  have  presented  symptoms  after  thirty  years 
of  age ;  and  the  majority  after  forty.  There  has  been  no  one  thing, 
nor  any  combination  of  circumstances,  which  has  occurred  with  such 
frequency  as  to  warrant  a  belief  in  its  operation  as  an  exciting  cause. 
Once  a  strained  position,  maintained  for  a  long  time;  occasionally 
exposure  to  cold ;  sometimes  a  sudden  shock,  either  mental,  moral,  or 
physical ;  and  at  other  times  the  presence  of  long-continued  anxiety, 
or  the  recurrence  of  pregnancy,  has  been  referred  to  by  the  patient  as 
the  cause  of  symptoms;  but,  in  regard  of  such  modes  of  causation,  we 
can  see  distinctly  that  which  might  lead  to  disturbance  of  the  nervous 
system  of  any  kind  whatsoever,  but  we  fail  to  see  anything  which 
should  conduce  to  this  special  form  of  derangement. 
*  In  one  case  that  I  have  seen  the  symptoms  were  preceded  by  hemi- 
plegia ;  in  another  by  paralysis  agitans  of  the  side  from  which  the 
head  was  turned ;  in  a  third,  arid  fourth,  and  fifth,  there  was  previous 
"writer's  cramp;"  in  a  sixth  there  was  histrionic  spasm  of  the  face; 
but  in  the  majority  of  cases  the  nervous  system  had  exhibited  no  prior 
derangement,  and  had  continued  free  from  ulterior  disturbance  for  a 
long  period  of  years. 

The  position  in  life  and  the  occupation  of  those  who  have  suffered 
from  Torticollis  have  varied  widely,  and  I  have  not  been  able  to  at- 
tribute the  malady  with  anything  like  constancy  to  that  common 
cause  of  nervous  disease — overwork. 

1  Syd.  Soc.  Transl.  of  Manual  of  Nervous  Diseases  of  Man.  vol.  i.  p.  316. 


188  DISEASES    OF    THE    NERVES. 

SYMPTOMS. — There  is  great  similarity  in  the  symptoms  presented  by 
different  individuals,  when  once  the  disease  is  established,  and  is  free 
from  accidental  complications.  Sometimes  the  commencement  is  sudden, 
but  much  more  commonly  it  is  gradual,  and  often  so  insidious  at  first 
that  the  real  nature  of  the  malady  is  overlooked.  The  patient  feels 
uneasy  in  the  neck,  thinks  that  something  is  wrong  with  his  cravat, 
or  with  his  pillow,  and  only  after  several  months  discovers  for  himself, 
or  is  told  by  others,  that  his  head  is  not  straight.  There  is  with  this 
want  of  symmetry  some  uneasiness  in  the  neck,  extending  from  the 
occipital  protuberance  downward  to  one  of  the  shoulders,  and  some- 
times onwards  into  the  arm,  or  even  forearm.  As  the  malady  advances 
the  uneasiness  becomes  greater,  and  sometimes  amounts  to  definite 
pain,  felt  usually  in  the  same  direction.  The  pain  is  increased  by 
voluntary  efforts  to  bring  the  head  into  the  middle  line,  but  sometimes 
attains  its  maximum  when  the  head  is  carried  round  to  the  furthest 
point  possible  by  the  spasmodic  movement.  The  pain  is  not  severe, 
but  generally  of  dull,  aching  character ;  and  often  is  relieved  by  lying 
down,  and  keeping  the  head  still  by  resting  it  upon  a  pillow. 

Observed  casually,  a  case  of  medium  severity  would  give  the  im- 
pression to  a  bystander  that  the  patient's  cravat  was  uncomfortable, 
and  that  he  was  trying  to  make  it  less  so  by  moving  the  head,  in  a 
somewhat  restless  manner,  towards  one  side;  or  that  he  was  making 
some  attempt  to  look  at  an  object  on  one  side  of  him,  which  object 
he  could  not  "get  his  head  round"  sufficiently  far  to  see  conveniently. 

Upon  more  careful  examination  it  is  seen  that  the  head  is  constantly 
being  moved  by  a  succession  of  jerks,  in  such  manner  that  the  occiput 
is  depressed,  and  the  chin  raised,  and  that  the  movement  is  in  a  defi- 
nite direction,  hour  after  hour,  and  month  after  month.  Early  in  the 
case  the  individual  is  able  so  far  to  antagonize  the  spasm,  by  a  simple 
voluntary  effort,  as  to  bring  the  head  into  the  middle  line,  or  even 
beyond  it;  but  as  time  passes  on  this  often  becomes  impossible,  and 
the  hands  are  used  to  pull  the  head  back  again  into  its  proper  posi- 
tion. 

When  Torticollis  has  existed  for  a  few  months  only,  the  head 
presents  a  constant  series  of  movements — the  spasm  and  the  voluntary 
effort  so  balancing  one  another  that  the  effect  is  that  described  above. 
But  when  it  has  lasted  for  a  longer  period,  the  head  is  habitually 
"carried  on  one  side;"  for  the  voluntary  interference  with  the  spasm," 
although  frequent — if  not  constant — does  not  suffice  to  bring  the 
head  into  a  central  position,  being  overcome  by  the  spasmodic  con- 
traction. Sometimes,  even  under  these  circumstances,  a  very  strong 
voluntary  effort  may  restore  momentary  equilibrium ;  but  the  effort 
is  attended  by  distress,  if  not  by  pain,  and  is  often  followed  by  an 
exaggeration  of  the  spasm. 

The  muscles  of  the  neck  on  the  side  from  which  the  chin  is  turned 
are  found  hard,  contracted,  and  often  hypertrophied ;  those'  on  the 
opposite  side  are  frequently  soft,  and  sometimes  wasted.  Early  in 
the  history  of  Torticollis  it  would  seem — so  far  as  my  experience  ex- 
tends— that  the  deeply  seated  muscles  at  the  back  of  the  neck  are 
most  affected ;  the  sterno-mastoid,  at  such  time,  being  often  free  from 


TORTICOLLIS.  189 

spasm.      At  a  later  period  the  sterno-mastoid  is  found  hard,  fre- 
quently hypertrophous. 

Occasionally  the  muscles  of  the  shoulder  are  so  involved  that  the 
acromion  is  raised  ;  more  rarely  the  muscles  of  the  face  present  his- 
trionic spasm;  and  not  unfrequently  there  is  some  difficulty  in  con- 
trolling the  movements  of  the  arm.  I  have  noticed  sometimes  difficulty 
of  deglutition,  and  in  a  very  few  cases  some  morbid  condition  of 
motility  in  the  leg ;  but  these  symptoms  must  be  regarded  as  compli- 
cations rather  than  conditions  of  the  disease  now  under  consideration; 
for  it  more  frequently  happens  that  the  muscles  of  the  neck  are  alone 
involved  in  the  morbid  contraction. 

As  a  rule,  to  which  the  exceptions  are  very  rare,  the  spasms  cease 
during  sleep  ;  and  not  only  so,  but  when  the  patient  lies  down  and 
supports  the  head.  They  are  increased  by  all  that  lowers  or  disturbs 
the  general  health,  and  by  emotional  excitement. 

The  electric  irritability  of  the  contracting  muscles  I  have  found 
much  increased  when  tested  by  faradisation :  the  electric  sensibility 
is  sometimes  so  greatly  augmented  that  an  interrupted  current,  not  in 
the  least  degree  painful  on  the  healthy  side,  was  perfectly  intolerable 
when  passed  through  the  seat  of  spasm.  It  has  appeared  often  that 
the  relaxed  muscles,  on  the  side  opposite  to  the  contraction,  have 
exhibited  less  than  their  normal  contractility ;  but  I  have  never  found 
them  so  defective  that  it  was  impossible  to  restore  the  head  to  equili- 
brium by  their  distant  faradisation.  This  battery  current,  when  con- ' 
tinuous,  and  passed  through  the  contracting  muscles,  relaxes  the 
spasm  and  allows  of  temporary  equilibrium ;  but,  when  interrupted, 
its  action  is  similar  in  kind  to  that  exerted  by  the  induced  current  of 
faradisation :  there  is,  however,  less  intensity  of  contraction,  and  much 
less  display  of  elastic  sensibility.  The  effects  of  either  the  battery 
current  or  of  faradisation  appear  to  be  singularly  transient,  in  what- 
ever manner  they  may  have  been  produced.  It  has  often  happened 
to  me  to  see  that  a  head  which  had  been  maintained  in  equilibria  for 
many  minutes,  and  that  day  after  day  for  a  considerable  number  of 
days,  returned  at  once  to  its  spasmodic  jerkings  the  moment  that  the 
application  was  suspended.  Sometimes  it  has  been  obvious  that  the 
spasm  was  subsequently  increased  by  the  electricity. 

The  side  to  which  the  twisting  occurs  has  been  sometimes  the  .right, 
sometimes  the  left.  There  appears  to  be  no  special  proclivity  to  the 
affection  of  one  side  rather  than  the  other  in  either  sex ;  but  when' 
once  the  malady  has  shown  itself,  its  pertinacity  is  remarkable:  it 
remains  in  exactly  the  same  position,  with  slight  tendency  to  extend ; 
or  it  may  in  rare  instances  disappear  for  eight  or  nine  years,  and  then 
return  to  the  member  that  it  had  previously  affected.  In  many  cases 
progress  is  so  slow  that  no  change  is  observable  after  several  years — 
i.e.,  no  change  as  to  locality — whereas  in  others  the  malady  seems  .to 
extend  either  upwards  or  downwards,  and  involve  muscles  not  impli- 
cated at  the  first.  •  In  this  manner  the  face  may  be  distorted,  or  the 
arm  may  be  rendered  partially  useless  by  either  rigidity  or  weakness; 
the  head  becomes  more  or  less  fixed  in  an  oblique  position,  the  ear 
of  one  side  being  drawn  down  to  the  shoulder,  and  the  chin  thrown 


190  DISEASES    OF    THE    NERVES. 

upwards  and  outwards  in  the  opposite  direction.  When  left  entirely 
to  itself — i.e.,  when  not  interfered  with  by  either  the  will,  the  ideas,  or 
emotions  of  the  patients,  or  by  any  influence  from  without — the  spasm 
is  tonic,  and  the  head  may  remain  for  hours  drawn  to  one  side,  but 
motionless.  This  is  rarely,  if  ever,  noticed  early  in  the  history  of  a 
cure,  and  sometimes  it  is  never  observed;  but,  even  when  it  occurs 
after  several  years'  duration  of  the  spasm,  the  slightest  emotional  dis- 
turbance or  attempt  at  voluntary  movement  brings  back  the  clonic 
contraction :  and  the  only  difference  to  be  recognized  between  the 
early  and  the  later  stages  of  the  malady  is,  that  in  the  latter  the  head 
is  never  brought  back  to  the  position  of  exact  equilibrium,  and  that 
there  is  less  obvious  movement  of  the  head  ;  for,  as  it  seems,  the 
habitual  struggle  between  volition  and  clonic  spasm  is  given  up,  and 
the  latter,  having  gained  the  day,  allows  tonic  spasm  to  take  its  place. 

The  mental  faculties,  the  sensibility  of  the  skin,  the  special  senses, 
and  the  general  health  undergo  no  necessary  changes  in  Torticollis. 
In  some  highly-marked  instances  there  has  been  complete  integrity 
of  function  in  every  direction ;  the  one  thing  that  has  been  wrong 
has  been  the  disease  itself.  Sometimes  the  general  health  has  been 
impaired,  the  patient  has  been  anaemic  and  weak ;  but  this  has  been 
frequently  the  result  of  the  annoyance  occasioned  by  the  spasm,  and 
very  rarely  the  supposed  cause  of  its  development. 

Numbness  and  anaesthesia  may  occur  in  the  arm,  together  with 
oadema,  when  the  scaleni  are  so  much  affected  as  to  press  upon  the 
brachial  plexus  and  its  adjacent  veins.1 

•  DIAGNOSIS. — The  symptoms  that  have  been  now  described  are 
sufficient  when  carefully  regarded  to  enable  the  practitioner  to  dis- 
tinguish this  disease  from  every  other.  An  accidental  exposure  to 
cold  may  produce  "stiff-neck  ;"  but  here  the  head  is  permanently  fixed 
in  one  position,  and  maintained  therein,  not  by  spasmodic  rigidity  of 
muscle,  but  by  the  fear  of  pain  which,  as  the  patient  knows,  any  move- 
ment may  occasion.  Such  malady  has  its  relations  to  pleurodynia, 
lumbago,  and  "  muscular  rheumatism  ;"  it  is  sudden  in  its  development, 
and  temporary  in  its  duration,  and  could  only  be  accidentally  mistaken 
for  Torticollis.  The  opposite  error  is  sometimes  made — viz.,  that  of 
regarding  genuine  spasmodic  Torticollis  as  a  simple  "stiff-neck  from 
rheumatism  or  cold."  In  its  earliest  stage,  however,  genuine  Torti- 
'collis  should  be  at  once  distinguished  by  the  clonic  character  of  the 
spasm,  and  freedom  from  pain  or  movement. 

Injuries  to  the  spine  occasionally  produce  stiffness  of  the  neck,  and 
this  to  such  a  degree  that  the  head  may  be  permanently  placed  in 
some  awkward  position.  In  such  cases  the  spasm  is  tonic;  there  is 
marked  tenderness  of  the  spinous  processes,  and  with  this  some  fulness 
or  hardness  around  or  behind  the  vertebral  column  ;  and  there  is  also 
some  impairment  of  the  motor  or  sensory  properties  in  the  arms  and 
legs. 

In  certain  organic  diseases  of  the  brain  accompanied  by  hemiplegia 
there  is  sometimes  Torticollis,  just  as  there  is  synergic  movement 

1  Romberg,loc.  cit.,p.  317. 


TORTICOLLIS.  191 

of  the  eyeballs;  but  the  mode  of  onset  of  symptoms  is  such  that  a 
case  of  cerebral  apoplexy  cannot  well  be  confounded  with  the  malady 
now  under  consideration.  The  opposite  mistake  has,  however,  some- 
times been  made,  and  an  individual  who  is  beginning  to  suffer  from 
Torticollis  spasmodica  has  been  supposed  to  be  the  subject  of  organic 
disease  of  the  brain.  For  the  distinction  between  these  two  very 
different  conditions  it  is  sufficient  to  bear  in  rnind  that  in  the  one  the 
disease  is  limited  to  the  neck,  in  the  other  it  occurs  in  combination 
with  marked  hemiplegia;  that  in  the  former  the  spasm  is  clonic,  in 
the  latter  tonic;  and  that  in  the  first  the  development  of  symptoms  is 
insidious,  gradual,  and  local,  whereas  in  the  second  it  is  sudden,  and 
of  wide  distribution. 

It  is  enough  to  mention  the  existence  of  cases  in  which  growths, 
benignant  or  malignant,  may  affect  the  position  of  the  head,  in  order 
to  prevent  the  occurrence  of  any  errors  in  diagnosis. 

PATHOLOGY. — Anatomical  inquiry  has  not  yet  shown  the  locality 
or  existence  of  any  special  lesion  of  the  nervous  centres  with  which 
Torticollis  is  necessarily  associated.  Physiological  experiment  has 
proved  that  it  may  exist  when  the  spinal  accessory  nerve  is  irritated 
at  its  passage  through  the  foramen  lacerum,1  or  when  injury  is  inflicted 
on  certain  muscles,  upon  the  olivary  body,  or  the  auditory  nerve.2 
The  disease  would  appear  to  be  one  of  those  curious  conditions — not 
yet  fully  understood — in  which  some  "centre"  of  associated  move- 
ments is  so  altered  that  there  follows  a  disturbance  of  the  normal 
equilibrium ;  a  disturbance  exhibiting  itself  at  first  by  dynamic  change, 
but  subsequently  leading  to  structural  alterations  in  the  affected 
muscles.  It  has  its  analogies  in  writer's  cramp  and  histrionic  spasm, 
and  its  peculiar  and  intimate  pathology  is  a  question  as  yet  reserved 
for  further  investigation. 

PROGNOSIS. — When  once  established — i.  e.,  when  fully  developed 
and  of  three  or  four  months'  duration — Torticollis  is  one  of  the  most 
obstinate  of  maladies.  It  has  sometimes  yielded  to  treatment,  under 
favourable  circumstances  ;  but  it  has  almost  invariably  recurred,  and 
has  proved  capable  of  resisting  all  efforts  made  for  its  relief. 

Unfortunate  as  the  prognosis  is  with  regard  to  the  cure  of  this 
special  malady,  there  is  one  ground  for  consolation — viz.,  that  it  is  not 
by  any  means  necessary,  nor  is  it  at  all  highly  probable,  that  the 
victim  of  Torticollis  should  suffer  from  any  other  nervous  disease. 
Sometimes  it  forms  but  part  of  a  general  nervous  disorder;  but,  as 
a  rule,  it  exists  alone;  and  although  it  may  continue  for  many  years, 
the  source  of  great  but  measurable  annoyance,  it  does  so  without 
entailing  any  danger  to  life,  or  any  high  probability  of  ulterior  change. 
Prognosis,  therefore,  is  based  upon  the  duration  of  the  disease,  and  its 
complication  with  other  signs  of  nervous  malady.  When  it  exists 
alone,  the  patient  may  look  forward  to  a  troublesome  and  obstinate 
affection;  but  he  may,  at  the  same  time,  know  its  limits,  and  be  di- 
rected to  go  on  without  fear  of  further  mischief. 

1  Volkmann,  quoted  by  Romberg,  loc.  cit.,  p.  316. 
*  Browu-Sgquard,  Lectures,  p.  194. 


192  DISEASES    OF    THE    NERVES. 

TREATMENT. — In  its  early  stages  Torticollis  has  yielded  to  various 
plans  of  treatment;  iron,  setons,  moxse,  rest,  mercurials,  electricity, 
and  the  division  of  nerves  or  of  muscles,  have  each  been  followed  by 
a  cure:  but  in  the  advanced  stages  no  one,  nor  any  combination,  of 
these  modes  of  treatment  has  availed  to  cure,  or  even  to  modify  the 
disease. 

I  have  used  all  kinds  of  soothing  applications,  have  employed 
electricity  in  every  form,  and  have  failed  to  influence  the  disease 
when  once  it  has  become  firmly  fixed ;  but  have  found  that  the  con- 
tinuous current  has  been  useful  when  the  malady  has  existed  for  a 
few  months  only,  and  have  also  at  that  period  seen  notable  advantage 
from  the  continued  application  of  morphia  by  the  method  of  hypo- 
dermic injection. 

It  would  seem  desirable  to  enjoin  rest;  to  secure  the  regulation  of 
the  general  health ;  to  apply  a  moderate  continuous  current  to  the 
muscles  which  exhibit  spasm,  and  a  mild  induced  current  to  their 
antagonists ;  and  to  inject  morphia,  hypodermically,  for  a  lengthened 
period.  It  is  not  essential  that  the  morphia  should  be  injected  into 
the  neck ;  it  may  be  introduced  into  the  arm  or  thigh,  or  any  other 
convenient  locality:  but  it  is  important  that  its  use  be  steadily  con- 
tinued, and  that  the  quantity  injected  be  gradually  increased  until 
a  definite  effect  is  produced  upon  the  spasm.  Beginning  with  the 
tenth  part  of  a  grain,  the  quantity  may  be  increased,  if  necessary, 
until  two,  or  even  three,  grains  are  injected  twice  daily ;  and  when 
the  patient  can  bear  this  amount,  the  spasm  has  sometimes  yielded. 
But  it  often  happens  that  morphia,  even  by  hypodermic  administration, 
cannot  be  borne,  from  the  fact  of  its  producing  nausea,  constipation, 
and  an  amount  of  malaise  that  is  greater  than  the  evil  it  is  intended 
to  relieve  ;  and  in  such  cases  the  Torticollis  is  positively  increased  by 
the  injection.  Several  patients  whom  I  have  known  with  Torticollis 
have  positively  refused  to  continue  the  injection  of  morphia  from  the 
misery  which  it  has  thus  occasioned. 

Mechanical  contrivances  have  been  employed  in  order  to  force  the 
head  into  position  ;  but  these,  although  so  managed  as  to  be  borne  for 
a  short  time — e.g.,  to  enable  a  clergyman  to  get  through  a  service,  or 
a  doctor  to  visit  two  or  three  patients  in  succession — are  often  found 
to  be  productive  of  so  much  annoyance,  or  even  pain,  that  the  patient 
would  rather  trust  to  his  own  hands  or  to  the  "  chapter  of  accidents" 
in  order  to  get  through  his  work.  The  most  simple,  and  at  the  same 
time  most  effective,  appliance  that  I  have  seen  for  mild  cases  is  that 
devised  by  Dr.  Hearne,  of  Southampton ;  but  it  has  failed  to  be  of 
service  when  the  disease  has  been  of  long  duration.  Mr.  Heather  Bigg 
has  constructed  several  machines  which  meet  the  difficulty  for  short 
periods  of  time ;  but  I  have  not  yet  seen  any  apparatus  which  a 
patient  with  confirmed  Torticollis  could  bear  habitually. 

Division  of  the  nerves  has  been  useless,1  and  division  of  the  sterno- 
mastoid  worse  than  useless,  for  it  has  led  to  an  exaggeration  of  the 
spasm  in  the  deeper-seated  muscles  at  the  back  of  the  neck,  as  I  had 
occasion  to  observe  in  a  well-marked  case  that  came  under  my  notice 
some  years  ago. 

1  Eomberg,  loc.  cit.,  p.  319. 


LOCAL    ANAESTHESIA;.  193 


VIII. 

LOCAL 

BY  J.  WARBURTON  BEGBIE,  M.D.,  F.R.C.P.E. 


THE  term  Anaesthesia  (o  privative,  (ueeijus,  sensibility),  indicates 
deprivation  or  loss  of  sensibility,  and  was  first  employed  by  the 
distinguished  Cappadocian  physician,  Aretaeus.1  There  exist  three 
abnormal  modifications  of  the  function  of  sensation  :  first,  it  may  be 
lost  ;  second,  it  may  be  exalted  (hyperassthesia)  ;  third,  it  may  be  per- 
verted. 

By  Local  Anaesthesia  we  understand  a  morbid  state  of  sensibility, 
in  which  the  normal  physiological  sensation  of  a  part  is  abolished 
entirely,  or  nearly  so. 

Since  the  introduction  of  ether  and  chloroform  inhalation,  for  the 
purpose  of  destroying  pain,  it  has  been  customary  to  describe  these 
valuable  agents  as  anaesthetics,  and  the  condition  of  insensibility  into 
which  the  person  is  thrown  by  their  action  as  Anesthesia.  With  this 
•interesting  phenomenon  we  have  at  present  no  concern. 

In  Local  Anaesthesia  the  want  or  failure  of  the  due  impression  must 
arise  from  a  morbid  state  of  the  extremities  of  nerves,  or  of  an  afferent 
nerve  ceasing  to  convey  the  impression  to  the  sensorium,  or  of  the 
sensorium  itself. 

Thus  we  are  entitled  to  limit  the  seat  of  the  morbid  influence, 
because  these  three  organs,  or  classes  of  organs,  are  concerned  in  the 
production  of  such  sensation. 

With  precisely  the  same  signification  as  Anaesthesia,  the  expression, 
paralysis  of  sensation,  or  of  the  nerves  of  sensation,  has  been  employed. 
It  were  better,  however,  to  abandon  the  use  of  paralysis  in  this  sense 
altogether,  and  to  restrict  it  to  the  loss  of  power  of  motion.  The  inti- 
mate connection  of  paralysis  and  Anaesthesia  is  abundantly  conspicu- 
ous :  the  latter  is  very  frequently  noticed  as  an  antecedent  phenomenon 
of  the  former,  or  they  occcur  simultaneously  ;  and  while  paralysis  lasts 
Anaesthesia  may  continue,  or  sensation  may  be  restored  long  before 
the  recovery  of  the  power  of  motion. 

The  special  situations  in  which  Anaesthesia  is  met  with,  or  may  be 
considered  apt  to  occur,  are  various.  For  convenience  of  illustration 
the  following  classification  may  be  made,  and  to  the  forms  now  to  be 

'  W  Jf  a<pft  IxXtt'mi  jU3uv>)  xo-ri  —  a-ita.vi.yi  JE  TJ  TGiovJs  —  cbmifBiffiri  juSXXjv  n  Tfaftrl;  xmXna-xsTai.— 
Uif]  lUtftK&ftHti  IlSfi  AITIWV  xai  ZapUM  Xpovtiv  UaSaav-  B.^Aiov  npurcv. 

13 


194  DISEASES    OF    THE    NERVES. 

mentioned  attention  will  be  very  briefly  directed  :  (a)  Anaesthesia 
of  the  skin  (cutaneous  Anaesthesia).  (6)  Anaesthesia  of  muscular 
nerves,  (c)  Anesthesia  of  sensorial  nerves,  (d}  Anaesthesia  of  the 
fifth  pair  of  nerves,  (e)  Anaesthesia  of  mucous  surfaces.  (/)  Anaes- 
thesia  of  the  viscera. 

(a)  Anaesthesia  of  the   Cutaneous  Nerves. — The  notable  and  lasting 
diminution,  or  the  entire  loss,  of  the  tactile  sense  of  the  skin  is  what  is 
understood  by  cutaneous  Anaesthesia.     It  is  by  a  careful  examination 
as  to  the  delicacy  of  tactile  sensibility,  and  the  perception  of  degrees 
of  temperature,  that  we  are  enabled  to  determine  the  extent  to  which 
Anaesthesia  of  the  surface  exists.     For  the  former  purpose  the  mere 
statements  of  the  patient  will  not  suffice.  Besides  measuring  the  degree 
and  determining  the  precise  seat  of  Anaesthesia  by  the  point  of  the 
needle,  recourse  must  be  had  to  the  method  of  experiment  suggested 
by  Weber,  testing  the  consciousness  of  the  patient,  while  blindfolded,  to 
the  two  points  of  a  pair  of  compasses  placed  at  different  parts  upon  the 
skin,  or,  which  is  still  more  satisfactory,  employing  the  delicate  little 
instrument  known  as  the  aesthesiometer  of  Dr.  Sieveking.     The  ready 
and  accurate  determination  by  the  patient  of  degrees  of  temperature, 
heat  and  cold,  is  impaired  or  destroyed  :  it  is  not  uncommon  to  find  hot 
things  styled  cold,  and  cold  things  hot.     In  marked  instances  of  cuta- 
neous Anaesthesia  the  power  of  resisting  the  injurious  influence  of 
temperature  is  lost;  and  not  only  so,  but,  owing  to  a  similar  defect, 
superficial  sores  are  readily  formed  on  parts  of  the  body  exposed  to 
even  a  slight  degree  of  pressure.    Evidence  of  the  derangement  of  the 
circulation  is  afforded  by  a  change  in  the  color  of  the  affected  part ; 
it  is  apt  to  become  livid  or  blue  in  appearance,  and  extravasations 
of  serum,  and  even  of  haematin,  occur.      Distressing  sensations  are 
experienced  by  the  patients — chiefly  numbness  and  pricking;    also* 
formication. 

In  alluding  to  the  treatment  of  cutaneous  Anaesthesia,  the  distin- 
guished German  writer  on  nervous  diseases  truly  observes,  "  Die 
Behandlung  der  Anesthesia  cutanea  war  bisher  eine  oberflachliche,  im 
wahren  Sinne  des  Wortes;"  but  while  this  is  to  be  regretted,  we  may 
reasonably  anticipate  an  increase  of  our  knowledge,  owing  to  .the 
much  more  satisfactory  manner  in  which  the  causes  and  seat  of  disease 
have  of  late,  and  are  at  the  present  time,  being  investigated. 

(b)  Anaesthesia  of  Muscular  Nerves. — The  loss  of  the  power  of  motion 
is  usually  unassociated  with  any  marked  degree  of  muscular  Anaes- 
thesia.    On  the  other  hand  instances  are  on  record  in  which  a  very 
perfect  insensibility  to  pain  has  existed  in  muscles,  while  the  power 
of  moving  them  has  been  retained.     It  is  of  the  utmost  importance 
to  distinguish  between  the  loss  of  tactile  sensation  (cutaneous  Anaes- 
thesia) and  the  definition  of  sensation  in  muscles,  for  without  care- 
fulness in  examination  these  two  are  capable  of  being,  and  in  some 
instances  have  no  doubt  been,  confounded.     Romberg  makes  the  inte- 
resting observation,  that  muscular  Anaesthesia,  without  the  loss  of 
or  any  damage  done  to  tactile  power,  exists  in  tabes  dorsalis.1 

1  Muskelaniisthesie. 


LOCAL    ANAESTHESIA.  195 

(c)  Anaesthesia  of  Sensorial  Nerves. — The    nerves  of  special  sense 
which  thus  suffer  are  the  optic    (Anaesthesia  optica),  the  Auditory 
(Anaesthesiaacoustica),  the  Olfactory  (Anaesthesia  olfactoria;  Anosmia), 
and  the  Gustatory  (Anesthesia  gustatoria ;  Ageustia).     To  the  many 
interesting  affections  included  under  these  terms — for  example,  ambly- 
opia  and  amaurosis  under  optic  Anaesthesia — it  is  quite  impossible 
in  this  brief   notice  of  Local  Anaesthesias  to  make  any  reference, 
while  such  important  diseases  demand  a  separate  and  detailed  con- 
sideration. 

(d)  Ansesthesia  of  the  Fifth  Pair  of  Nerves  (Facial  or  Trigeminal 
Anaesthesia).  —  Physiological   experiments   have    demonstrated    the 
remarkable  effects  produced   by  section  of  the  fifth  pair ;  of  these 
insensibility  of  the  face,  eye,  nostrils,  cavity  of  the  mouth  and  tongue, 
is  the  most  conspicuous:    while  the  extent  of  the  Anaesthesia  is  of 
course  determined  by  the  nervous  injury  being  limited  to  one  or  more 
branches,  or,  on  the  other  hand,  involving  the  trunk  before  division. 
Experimental  inquiry,  as  well  as  clinical  observation,  have  further 
shown    that   when   injury  or   lesion  of  the  nerve  exists  within  the 
cranium,  the  resulting  phenomena  are  not  such  as  are  included  in 
Anaesthesia  merely,  but  paralysis  and  impairment  or  loss  of  special 
sense  are    also  induced.      Kornberg,1  in   directing   attention   to  the 
different  diagnostic  symptoms,  has  indicated  certain  very  important 
particulars,  as  follows:    (a)  The  more  the  Anaesthesia  is  confined  to 
single  filaments  of  the   fifth    pair,  the  more  peripheral  the  seat  of 
the  cause  will  be  found  to  be.     (V)  If  the  loss  of  sensation  affects  a 
portion  of  the  facial  surface,  together  with  the  corresponding  facial 
cavity,  the  disease  may  be  assumed  to  involve  the  sensory  fibres  of 
the  fifth  pair  before  they  separate  to  be  distributed  to  their  respective 
destinations;  in  other  words,  a  main  division  must  be, affected  before 
or   after   its   passage   through   the   cranium,      (c)  When  the  entire 
sensory  tract  of  the  fifth  nerve  has  lost  its  sensation,  and  there  are  at 
the  same  time  derangements  of  the  nutritive  functions  in  the  affected 
parts,  the  Gasserian  ganglion,  or  the  nerve  in  its  immediate  vicinity,  is 
the  seat  of  the  disease,     (d)  If  the  Anaesthesia  of  the  fifth   nerve  is 
complicated  with  disturbed  functions  of  adjoining  cerebral  nerves,  it 
may  be  assumed  that  the  cause  is  seated  at  the  base  of  the  brain. 
Thus  facial  Anaesthesia,  as  a  phenomenon  of  disease,  may  be  in  itself 
a  simple,  really  trivial,  affection,  or  it  may  be  the  indication  of  serious 
organic  disease.    In  the  former  case  it  will  be  apparently  indepen- 
dent and  isolated  ;  in  the  latter,  linked  with  other  striking  features,  its 
significancy  will  as  little  escape  observation  as  its  existence. 

Facial  Anaesthesia  in  some  instances  comes  on  gradually  ;  in  others 
its  occurrence  is  sudden.  Neuralgic  pain,  or  a  condition  of  local 
hyperaesthesia,  may  precede  its  development ;  while  facial  palsy  and 
facial  Anaesthesia  are  occasionally  associated. 

(e  and  /)  Anaesthesia  of  Mucous  Surface,  and  of  the  Viscera. — The 
morbid  condition  in  such  circumstances  must  depend  on  a  failure  of 
the  sympathetic  to  conduct  the  impression  to  the  brain ;  but,  as  a 

1  Anasthesie  des  Quintus  LehrbucU  der  Nervenkranklieiten. 


DISEASES    OF    THE    NERVES. 

general  rule,  impressions  made  on  the  ganglionic  nervous  system  are 
not  thus  conveyed  and  it  requires  a  powerful  irritation,  or  condition 
of  notable  hyperaBSthesia,  in  order  that  a  consciousness  of  their  ex- 
istence should  be  established.  The  inquiry  into  the  operation  of  the 
organic  nervous  system  is  one  of  very  great  difficulty,  and  Romberg 
has  truly  remarked  in  regard  to  it,  "Von  vorn  herein  bekennen  wir 
unsre  unbekanntschaft  mit  diesen  Zustanden,  die  bisher  nicht  einmal 
zur  Sprache  gekommen  sind,  und  deren  Forschung  mit  grossen 
Schwierigkeiten  verbunden  1st." 


r" 


Date  Due 


PRINTED  IN   U.S.A.  CAT.     NO.     24      16) 


wiAoo 
o  58 
1871 

On  diseases  of  the  spine  and  of  the 
nerves . 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


